Citation Nr: 21000226 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 17-30 325 DATE: January 4, 2021 ORDER A rating higher than 10 percent for tinnitus is denied. A rating higher than 10 percent for right knee strain status post partial lateral meniscectomy is denied. A compensable rating for right knee limited extension prior to November 16, 2015, is denied. A rating higher than 10 percent for right knee limited extension, from November 16, 2015, to April 14, 2018, is denied. A 10 percent rating for right knee limited extension as of April 14, 2018, is granted. A rating higher than 10 percent for left eye optic neuritis is denied. A 70 percent rating, but not higher, for posttraumatic stress disorder with obsessive compulsive disorder, generalized anxiety disorder not otherwise specified, and depressive disorder not otherwise specified (PTSD) prior to November 16, 2015, is granted. A rating higher than 70 percent for PTSD from November 16, 2015, to December 1, 2017 is denied. FINDINGS OF FACT 1. The Veteran’s tinnitus does not necessitate frequent hospitalizations, markedly interfere with his capacity for employment, or otherwise present an exceptional disability picture. 2. Throughout the appeal period, the Veteran’s right knee disability has manifested as residuals of a meniscal condition including pain, weakness, fatigability, and noncompensable limitation of motion with subjective complaints of buckling on extension, swelling, tingling, and giving way. 3. The Veteran’s left eye optic neuritis manifests as impaired color vision and visual field impairment manifests as decreased color differentiation and visual field loss with average concentric contraction of no less than 36 degrees, but no other visual impairment as his corrected visual acuity was consistently 20/40 or better and he has no impairment of muscle function or associated incapacitating episodes. 4. Prior to November 16, 2015, the Veteran’s posttraumatic stress disorder (PTSD) manifested as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, characterized by depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, panic attacks, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, hypervigilance, and suicidal ideation; total occupational and social impairment were not shown. 5. From November 16, 2015, to December 1, 2017, the Veteran’s posttraumatic stress disorder (PTSD) manifested as occupational and social impairment with deficiencies in most areas with additional symptoms including obsessional rituals which interfere with routine activities and episodes of self-harm (cutting and punching himself); total occupational and social impairment was not shown. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.321 (b)(1), Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.87, Diagnostic Code (DC) 6260. 2. The criteria for a disability rating higher than 10 percent for right knee strain status post partial lateral meniscectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5260. 3. Prior to November 16, 2015, the criteria for a compensable disability rating for right knee limited extension were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DC) 5010-5261. 4. From November 16, 2015, to April 14, 2018, the criteria for a disability rating higher than 10 percent for right knee limited extension were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DC) 5010-5261. 5. As of April 14, 2018, the criteria for a disability rating of 10 percent for right knee limited extension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DC) 5010-5261. 6. The criteria for a disability rating in excess of 10 percent for left eye optic neuritis have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79 Diagnostic Code (DC) 6026. 7. Prior to November 16, 2015, the criteria for a 70 percent disability rating for posttraumatic stress disorder (PTSD) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 8. From November 16, 2015, to December 1, 2017, the criteria for a disability rating in higher than 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 2006 to July 2009 and from September 2012 to January 2014. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for left eye optic neuritis, bilateral tinnitus, right knee strain status post partial lateral meniscectomy, right knee limited extension, and right knee scars; decreased his rating for lumbar spine spondylosis; denied an increased rating for posttraumatic stress disorder (PTSD_ with obsessive compulsive disorder generalized anxiety disorder, and depressive disorder; and denied service connection for right eye condition, headaches, bilateral hearing loss, and left knee condition. In a July 2014 notice of disagreement, the Veteran appealed the ratings assigned for left eye optic neuritis, bilateral tinnitus, right knee strain status post partial lateral meniscectomy, right knee limited extension, and PTSD. In a November 2014 Board decision, these issues were remanded for issuance of a statement of the case. In February 2020, the Board again remanded these issues for issuance of a statement of the case. The RO issued a statement of the case in July 2020. Confusingly, the was labelled as a supplemental statement of the case and instructed the Veteran that the case was being returned to the Board without instructing him that any additional actions, such as a substantive appeal (VA Form 9), were required on his part. This case has since been recertified to the Board. The Veteran’s representative issued a post-remand brief in November 2020; thus, relying on the mischaracterization of these issues as already perfected for appeal. As such, the Board accepts them as perfected and, below, will address them on the merits. Percy v. Shinseki, 23 Vet. App. 37, 41 (2009). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 1. A rating higher than 10 percent for tinnitus The Veteran was originally granted service connection for tinnitus in a June 2014 rating decision. At that time, he was assigned a 10 percent rating effective January 7, 2014. The Veteran appealed that decision, seeking a rating higher than 10 percent. The rating schedule provides for evaluating recurrent tinnitus at 10 percent, whether the sound is perceived in one ear, both ears, or the head. 38 C.F.R. § 4.87, Diagnostic Code (DC) 6260, Note (2). A 10 percent is the only and highest rating for tinnitus provided under the rating schedule. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant’s disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). The April 2014 hearing loss and tinnitus disability benefits questionnaire (DBQ) noted the Veteran’s complaints of intermittent bilateral tinnitus, which became constant in December 2012, during his deployment. He reported that tinnitus was irritating and affected his concentration. There is no evidence that the Veteran’s tinnitus necessitates frequent hospitalizations. Although he reports interference with concentration and focus, there is likewise no showing of marked interference with his capacity for employment. Moreover, the record does not suggest, and the Veteran has not alleged any other symptoms that would present an exceptional disability picture for his tinnitus. As the rating schedule provides for no higher than a 10 percent rating for tinnitus, and there is no basis to consider an extraschedular rating, the Board denies a rating higher than 10 percent for the Veteran’s tinnitus. 2. Increased ratings for right knee disability The Veteran was originally granted service connection for right knee strain status post partial lateral meniscectomy, right knee limited extension, and right knee scars in the June 2014 rating decision on appeal. At that time, his right knee strain status post partial lateral meniscectomy was assigned a 10 percent rating while his limitation of extension and scars were assigned noncompensable (0 percent) ratings, all effective January 7, 2014. In his July 2014 notice of disagreement, the Veteran appeal the ratings assigned for right knee strain status post partial lateral meniscectomy and limited extension. In a March 2017 DRO decision, the Veteran’s rating for right knee extension was increased to 10 percent effective November 16, 2015, thereby staging this rating. Thereafter, in a May 2018 rating decision decreased the Veteran’s rating for right knee limited extension to 0 percent effective April 14, 2018. Currently, the Veteran’s right knee strain status post partial lateral meniscectomy is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5260, for limitation of flexion of the leg and his limitation of extension is rated under hyphenated diagnostic code 5010-5261. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. DC 5010 for traumatic arthritis, instructs the rater to rate based on the criteria for degenerative arthritis (DC 5003). DC 5003 provides rating criteria for degenerative arthritis substantiated by x-ray findings, rated either on limitation of motion of the affected joint under the appropriate diagnostic code or, if only a noncompensable limitation of motion is found, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating is warranted if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is warranted if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id. Under DC 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. DC 5261 provides rating criteria for limitation of extension of the knee. Under DC 5261, a 10 percent rating will be assigned for limitation of extension of the knee to 10 degrees; a 20 percent rating will be assigned for limitation of extension to 15 degrees; and a 30 percent rating will be assigned for limitation of extension to 20 degrees. 38 C.F.R. § 4.71a, DC 5261. Normal range of motion of the knee is zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71a, Plate II. If the criteria for a compensable rating under both DC 5260 and DC 5261 are met, separate ratings can be assigned. VAOPGCPREC 9-2004 (Sept. 17, 2004). Similarly, a claimant who has both arthritis and instability of the knee may be rated separately under DC 5010 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The April 2014 knee and lower leg conditions DBQ notes the Veteran’s complaints of pain with increased activities, which led to limping and occasional buckling. He denied any locking. Any running or prolonged walking aggravated his right knee. He reported flare-ups that affected his ability to go out, go to school, and perform military duties. Range of motion testing found full extension bilaterally with no objective evidence of painful motion. Flexion of the right knee was limited to 130 degrees with objective evidence of pain at 125 degrees. Flexion of the left knee was limited to 135 degrees with no objective evidence of pain. Given his girth, the normal variant for flexion was 135 degrees. The examiner noted that an additional 10-degree loss of flexion and five-degree loss of extension in the right knee would be expected during painful flare-ups or repetitive activity due to mild to moderate weakness, moderate fatigability, and mild to moderate loss of coordination. The Veteran was able to perform repetitive use testing on both knees without additional functional loss or limitation of motion. His functional impairment of the right knee included less movement than normal, weakened movement, excess fatigability, pain on movement, and interference with sitting, standing, and weight bearing. His right knee had tenderness or pain to palpation for joint line or soft tissues. He had slightly decreased (4/5 – active movement against some resistance) muscle strength in both flexion and extension of the right knee. Stability testing was normal. There was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran did not have a history of or currently have recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did have a history of meniscus condition in the right knee that caused frequent episodes of joint pain. He had undergone a partial lateral meniscectomy in May 2013. The associated residuals were pain, weakness, fatigability, and decreased range of motion. He had not undergone a total knee replacement or any other knee surgery. He had well-healed associated scars that were not painful, unstable, or greater than 39 square centimeters in area. He occasionally used crutches postoperatively. The Veteran’s disability did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Imaging studies confirmed right knee arthritis, but not patellar subluxation or any other significant diagnostic test finding or results. This disability impacted the Veteran’s ability to work in that he would not be well suited for physically demanding employment requiring repetitive bending squatting and carrying or lifting but would be able to perform sedentary employment due to his right knee condition. In his July 2014 notice of disagreement, the Veteran stated that he was having increasing issues with right knee extension. His knee would buckle on extension and was painful after use. A November 2014 private treatment record notes the Veteran’s complaints of swelling, tingling, giving way, and pain in his right knee. His pain prevented running and physical training for Reserves. Anti-inflammatories did not help. Prolonged sitting, squatting, or kneeling increased his pain. He was unable to walk regularly and had gained 35 pounds. Examination of the right knee found no joint effusion. He was uncomfortable in the retropatellar region with terminal extension and kept the knee flexed to 5 degrees. Pain limited flexion to 105 degrees. The left knee had full extension and flexion to 130 degrees. The Veteran was reactive both of the medial joint line and patellofemoral compartments. No patellar instability was noted and there was no crepitus present. McMurray’s did not reproduce medially based pain. The lateral compartment was nontender to palpation. There was no varus or valgus instability noted, and Lachman’s was negative. There was poor proprioception and weakness of the quadriceps with single leg step-up. Resisted knee extension also reproduced anteriorly based symptoms. X-rays showed no fractures, loose bodies, or lytic lesions. Mild lateralization of the patella bilaterally and small lateral tibial osteophytes were appreciated. A December 2014 private treatment record notes a small lateral meniscus cyst, but no recurrent tear or significant chondral damage. His cruciate ligaments were intact tricompartmentally. Prolonged standing or coming to full extension were the worst positions. He had difficulty flexing his knee past 115 degrees. Examination of the right knee found no effusion. His range of motion was from zero to 120 degrees with pain in full extension and in flexion past 100 degrees. His pain was isolated primarily retro-patellar and anteromedial, anterolateral. There was no pain with McMurray’s and no significant joint line tenderness. This physician felt that the Veteran’s symptoms were likely impinging anteromedial plical scar tissue and fat. Arthroscopic debridement was recommended. The accompanying MRI found a horizontal tear of the right lateral meniscus. A November 16, 2015 knee and lower leg conditions DBQ notes the Veteran’s report that since his April 2014 exam his right knee gave out, bending backwards several times a day while walking. This knee also tended to bend or give way. He reports a history of falling but is unsure if it is related to his knee or multiple sclerosis. Prolonged sitting and standing are bothersome. Pain interfered with sleep. Over-the-counter medications did not fully help. At time, his right knee would swell on the outer side. He reported flare-ups of pressure behind the kneecap that prevented him from maneuvering adequately and slowing him down to the point he had to ask for help from a coworker. Range of motion testing found right knee range of motion from 10 degrees to 75 degrees with pain noted on examination, in both extension and flexion, that resulted in functional loss. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the medial and lateral joint line. There was no objective evidence of crepitus. In the left knee, his range of motion was from zero to 135 degrees, which was normal range of motion given his thigh size. No pain was noted on examination. There was no evidence of pain with weight bearing. There was objective evidence of mild joint line tenderness of unknown etiology. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing on both knees without additional functional loss or limitation of motion. The Veteran was not examined immediately after repetitive use over time, and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to state without resorting to speculation whether pain, weakness, fatigability, or incoordination significantly limit the Veteran’s functional ability with repeated use over a period of time because he was not examined under these conditions. The examiner indicated that this examination was conducted during a right knee flare-up, but was still unable to state without resorting to speculation whether pain, weakness, fatigability, or incoordination significantly limit the Veteran’s functional ability during a flare-up because he was not examined under these conditions. The Veteran did not report left knee flare-ups. The Veteran had full muscle strength bilaterally without atrophy. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing found no instability in either knee. The Veteran did not have a history of or currently have recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did have a history of meniscus condition that caused frequent episodes of joint pain. He had undergone a partial lateral meniscectomy in 2013 with residual pain, fatigability, and decreased range of motion. He had an associated suprapatellar portal scar measuring 1 cm by 0.2 cm, but this was not painful or unstable. He occasionally used a brace for his right knee disability if he knew he was going to be on his feet more than usual. The Veteran’s disability did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Imaging studies confirmed right knee arthritis and torn meniscus. This disability impacted his ability to work in that prolonged walking, standing, climbing, or squatting were impaired. This examiner noted that observed ranges of motion during distraction versus measured ranges of motion during formal exam were inconsistent. This likely indicated significant behavioral responses to examination, and therefore symptoms, measured ranges of motion, and related examination findings were not reliable indicators of pathology or disability. The Veteran reported that he could move his right knee over a greater range of motion, but preferred not to do so due to pain. He walked with full extension of the right knee, and flexion of the right knee was possible beyond 90 degrees. The Board finds the examiner’s observed range of motion, which reflects the range of motion of the right knee when in normal use, more probative than the range demonstrated during the range of motion testing. The March 2017 knee and lower leg conditions DBQ notes that the Veteran was having a flare-up of his right knee disability at the time of the examination. He stated that his right knee hurt all of the time and his left knee hurt 60 percent of the time. The pain was worse with physical activity and any weight bearing activity. He described functional impairment and loss as an inability to stand or sit for more than an hour at a time before needing to change position due to pain. He was not able to run as it caused pain. His pain was predominantly in the right knee, but he also had pain in the left knee. Range of motion testing found right knee range of motion from zero degrees to 90 degrees with pain noted on examination, in both extension and flexion, that resulted in functional loss. There was evidence of pain with weight bearing and with passive range of motion, but not when joint was used in non-weight bearing. There was objective evidence of localized tenderness to firm palpation of the medial and lateral joint line. There was no objective evidence of crepitus. In the left knee, his range of motion was from zero to 120 degrees with pain on flexion. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or crepitus. The Veteran was able to perform repetitive use testing on both knees without additional functional loss or limitation of motion. The Veteran was not examined immediately after repetitive use over time, and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to state without resorting to speculation whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated used over a period of time because he was not observed directly under these conditions. The examiner indicated that this examination was conducted during a right knee flare-up. Pain and lack of endurance significantly limited the Veteran’s functional ability during a flare-up. He was not examined during a left knee flare-up, and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during left knee flare-ups. The examiner was unable to state without resorting to speculation whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability during a left knee flare-up because he was not observed directly under these conditions. The Veteran reported a current right knee flare-up and had a limp with weight predominantly on the left leg. He stated that his gait was usually normal when not having a flare-up. The Veteran had full muscle strength bilaterally without atrophy. He did not have ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing found no instability in either knee. The Veteran did not have a history of or currently have recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did have a history of a right meniscal tear treated in May 2013. He did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to this disability. He had an associated suprapatellar portal scar measuring 1 cm by 0.2 cm, but this was not painful or unstable. He did not use an assistive device as a normal mode of locomotion. The Veteran’s disability did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. This disability impacted his ability to work in that prolonged walking, sitting, and weight bearing were limited by his knees, mainly the right knee. The April 14, 2018 knee and lower leg conditions DBQ notes the Veteran’s reports of right knee pain and a sense of instability. He was still having buckling even after arthroscopic surgery. He was unable to run or strength train his lower limbs due to pain. Prolonged sitting caused knee pain. His knee pain was better with changing positions, like a sit-to-stand desk. He reported flare-ups of aggressive pain and feeling unstable. The knee would buckle while standing and cause unexpected flexion or extension. He reported functional loss with running, jogging, and impact activity. Right knee range of motion testing found full extension and flexion limited to 105 degrees. This caused difficulty squatting. Pain was noted in both extension and flexion. The Veteran’s passive range of motion was the same as his active range of motion. He had objective evidence of moderate localized tenderness or pain to palpation of the joint or associated soft tissue in the lateral joint line right knee related to strain. There was objective evidence of pain when the right knee was used in non-weight bearing. There was no evidence of pain with weight bearing or objective evidence of crepitus. Left knee range of motion testing was all normal in both active and passive range of motion testing. There was no evidence of left knee pain with weight bearing or non-weight bearing. There was not objective evidence of crepitus in the left knee. The Veteran was able to perform repetitive use testing on both knees without additional functional loss or limitation of motion. The Veteran was not examined immediately after repetitive use over time, and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain significantly limited right knee functional ability with repeated use over a period of time, but the examiner was unable to describe this in terms of range of motion because the Veteran reported variable loss of motion depending on how strenuously the joint was used. At its worst, the Veteran could not move it at all due to pain, but there were other times where the loss of range of motion was minimal compared to that which was measured on the day of the exam. The Veteran was not examined during a flare-up, and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during a flare-up. Pain significantly limited right knee functional ability during a flare-up, but the examiner was unable to describe this in terms of range of motion because the Veteran reported variable loss of motion depending on pain severity level. Again, at its worst, the Veteran could not move the knee at all due to pain, but there were other times where the loss of range of motion was minimal compared to that which was measured on the day of the exam. Additional contributing factors of right knee disability included disturbance of locomotion, interference with standing, and interference with running, jogging, and lower limb weightlifting. He had full muscle strength bilaterally without atrophy. He did not have ankylosis in either knee. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing found no instability in either knee. The Veteran did not have a history of or currently have recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did have a history of a right meniscectomy in April 2014. He did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to this disability. He had small associated scars that were not painful or unstable. He did occasionally used a brace for right knee pain and buckling. The Veteran’s disability did not result in functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. This disability impacted his ability to work in that he had knee pain with prolonged sitting or standing and required frequent change of position. Based on the above, throughout the pendency of this appeal, the Veteran’s right knee disability was manifested as residuals of a meniscal condition including pain, weakness, fatigability, and decreased range of motion. The measured range of motion at the time of the November 16, 2015, DBQ included extension limited to 10 degrees, which would warrant a 10 percent rating under DC 5261; however, the examiner clarified that the Veteran’s observed range of motion during the remainder of the examination showed full range of extension when walking. As such, the Board finds the examiner’s observed range of motion, which reflects the range of motion of the right knee when in normal use, more probative than the range demonstrated during the range of motion testing. The Veteran also reported subjective symptoms of buckling on extension, swelling, tingling, and giving way. His decreased range of motion included limitation of flexion of no less than 90 degrees and full extension with an anticipated five-degree loss during painful flare-ups or repetitive activity due to mild to moderate weakness, moderate fatigability, and mild to moderate loss of coordination. This represents noncompensable limitation of motion in both flexion and extension, and so the Veteran was awarded a 10 percent rating based on painful motion. See 38 C.F.R. § 4.71a, DC 5010, 5260, 5261. A higher rating is not warranted based on limitation of motion, but the Board finds that the 10 percent for extension should be extended past April 14, 2018, as there was no showing of material improvement in overall symptoms. To that extent only, the appeal is granted. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). There was no finding of ankylosis, so a rating under DC 5256 is not warranted. Despite subjective complaints of instability, objective stability testing was repeatedly normal, and the Veteran did not have recurrent patellar subluxation/dislocation of the right knee. Therefore, a rating under DC 5257 was not warranted. Likewise, there was no evidence of malunion or nonunion of the tibia and fibula upon which a rating under DC 5262 could be based. Finally, the record does not show genu recurvatum; thus, DC 5263 is not applicable. The Veteran underwent a partial meniscectomy in May 2013. If this partial meniscectomy is treated as symptomatic removal of semilunar cartilage under DC 5259, a 10 percent rating would be warranted. See 38 C.F.R. § 4.71a. This rating would replace the existing 10 percent rating as the stated symptoms are pain and limitation of motion, which forms the basis for the 10 percent rating under DC 5010. With regard to DC 5259, the December 2014 private treatment record confusingly states no recurrent meniscal tear while the accompanying MRI shows a tear. Nevertheless, while the Veteran reported a history of episodes of pain, the record does not show frequent, or indeed any, episodes of locking, and physical examination repeatedly found no effusion. As such, a 20 percent rating under DC 5259 for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion is not warranted. The Veteran is currently service connected for associated scar with a noncompensable (0 percent) rating, which he did not appeal. The evidence of record, which shows small, stable, and not painful scarring of the knee does not suggest any symptoms which would warrant reconsideration of that rating. Thus, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for right knee strain status post partial lateral meniscectomy throughout the appeal period. Additionally, the preponderance of the evidence is against the Veteran’s claim for a compensable rating for right knee limitation of extension prior to November 16, 2015 and a rating higher than 10 percent for right knee limitation of extension from November 16, 2015, to April 14, 2018; however, the Board has determined that the 10 percent evaluation should be extended past April 14, 2018 in the absence of a showing of material improvement. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. A rating higher than 10 percent for left eye optic neuritis The Veteran was originally granted service connection for left eye optic neuritis in the June 2014 rating decision on appeal. At that time, this disability was assigned a 10 percent rating effective January 7, 2014. The Veteran’s left eye optic neuritis is currently rated under hyphenated diagnostic code 6026-6080. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. In this case, DC 6026 provides criteria for optic neuropathy and DC 6080 provides criteria for visual field defects. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15,316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Under the former criteria, DC 6026 instructed to evaluate optic neuropathy based on visual impairment.  Under the revised criteria, DC 6026 instructs to evaluate optic under the General Rating Formula for Diseases of the Eye. Under the revised criteria, the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. The criteria for visual impairment, including impairments of visual acuity, visual fields, and/or muscle function, have remained unchanged. Impaired visual acuity is rated under diagnostic codes 6061-6066 based on the best corrected distance vision. 38 C.F.R. §§ 4.76, 4.79. Impairment of visual fields are rated under DC 6080-6081 based on the average concentric contraction of the visual field of each eye; asymmetric impairments are converted to their visual acuity equivalents. 38 C.F.R. §§ 4.77, 4.79. Impaired muscle function is rated under DC 6090-6091 with an evaluation for diplopia being assigned to only one eye. 38 C.F.R. §§ 4.78, 4.79. Diagnostic Code 6080 provides that concentric contraction of visual field to 5 degrees warrants a 100 percent disability rating for bilateral loss, a 30 percent disability rating for unilateral loss, or is rated as 5/200 (1.5/60). Concentric contraction of visual field to 15 degrees, but not to 5 degrees, warrants a 70 percent disability rating for bilateral loss, a 20 percent disability rating for unilateral loss, or is rated as 20/200 (6/60). Concentric contraction of visual field to 30 degrees, but not to 15 degrees, warrants a 50 percent disability rating for bilateral loss, a 10 percent disability rating for unilateral loss, or is rated as 20/100 (6/30). Concentric contraction of visual field to 45 degrees, but not to 30 degrees, warrants a 30 percent disability rating for bilateral loss, a 10 percent disability rating for unilateral loss, or is rated as 20/70 (6/21). Concentric contraction of visual field to 60 degrees, but not to 45 degrees, warrants a 20 percent disability rating for bilateral loss, a 10 percent disability rating for unilateral loss, or is rated as 20/50 (6/15). Bilateral loss of the temporal half of the visual field warrants a 30 percent disability rating, unilateral loss warrants a 10 percent disability rating, or is rated as 20/70 (6/21). Bilateral loss of the nasal half of the visual field warrants a 20 percent disability rating, unilateral warrants a 10 percent disability rating, or is rated as 20/50 (6/15). 38 C.F.R. § 4.84a, Diagnostic Code 6080 (2008). The normal visual field extent at eight principal meridians is (expressed in degrees): Temporally: 85, Down temporally: 85, Down: 65, Down nasally: 50, Nasally: 60, Up nasally: 55, Up: 45, Up temporally: 55. The combined sum is 500. To calculate the visual field, determine the average concentric contraction of the visual field of each eye by measuring the remaining visual field (in degrees) at each of eight principal meridians 45 degrees apart, adding them, and dividing the sum by eight. 38 C.F.R. § 4.76a. When only one eye is service connected, the other eye considered 20/40 for rating purposes regardless of the actual level of impairment. 38 C.F.R. § 4.75(c). In his March 2014 statement, the Veteran reported losing vision in his left eye over the course of three days in December 2013. He was treated and, after one month, began to partially regain his vision. He reported current left eye symptoms of blurred vision, inability to differentiate colors, and headaches. He also felt that his left eye was negatively impacting his vision in his right eye. He stated that his left eye disability impacted his daily life, including his work as a Reservist and his schooling. At the time of his May 2014 VA eye conditions DBQ, the Veteran reported blurriness and problems with color vision. His distance visual acuity was 20/40 or better bilaterally with and without correction. Uncorrected, his near vision was 20/40 in the right eye and 20/50 in the left eye, both corrected to 20/40 or better. His pupils were symmetric, round, and reactive to light. There was an afferent pupillary defect in the left eye. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness of either eye. He did not have a corneal irregularity that resulted in severe astigmatism. He did not have diplopia. An external eye examination was normal. Internally, his left optic disc had 1+ diffuse pallor. The Veteran had a visual field defect with contraction of his visual field in the left eye described as 30 degrees up, 30-67 degrees up temporally, 72 degrees temporally, 40-70 degrees down temporally, 50 degrees down, 26-40 degrees down nasally, 26 degrees nasally, and 27-36 degrees up nasally. Contraction of the visual field in the right eye was described as 22 degrees up, 26-70 degrees up temporally, 67 degrees temporally, 40-67 degrees down temporally, 33 degrees down, 20-33 degrees down nasally, 27 degrees nasally, and 28-30 degrees up nasally. The Board notes that the range given for the secondary meridians reflects the range of the three points plotted on the Goldmann chart for each, whereas only the central meridian of each set is used for rating purposes. Therefore, only the relevant measurement is noted in the chart below. The Veteran did not have a scotoma. His visual field impairment did not result in statutory blindness. The Veteran’s vision loss was attributed to his left optic neuropathy. He did not have any other eye conditions, pertinent physical findings, complications, conditions, signs, or symptoms related to his eye disability. He did not have any scarring or disfigurement attributable to any eye condition. In the prior twelve months, he had not had any incapacitating episodes attributable to any eye condition. This disability impacted his ability to work in that he would not be able to perform work that required intact peripheral vision. He also had partial color vision loss. The accompanying visual field perimeter chart showed some loss of visual field as described below: Meridian Normal Right Eye Left Eye Up 45 30 22 Up temporally 55 40 40 Temporally 85 72 67 Down temporally 85 65 52 Down 65 50 33 Down nasally 50 30 23 Nasally 60 26 27 Up nasally 55 25 25 Total: 500 338 289 Average Concentric Contraction 62.5 42.25 36.125 A September 2015 VA treatment record noted full visual fields. In his July 2014 notice of disagreement, the Veteran stated that his left eye had never fully recovered following his optic neuritis. He continued to have impaired vision, impeding into his right eye, and difficulty differentiating colors. This impeded his daily activities. The November 2015 VA eye conditions DBQ notes the Veteran’s reports of worsening vision, but not eye pain. His uncorrected visual acuity was 20/40 or better in the right eye and 20/50 in the left for both distance and near vision, all corrected to 20/40 or better. His pupils were symmetric, round, and reactive to light. There was an afferent pupillary defect in the left eye. The Veteran did not have anatomical loss, light perception only, extremely poor vision or blindness of either eye. He did not have a corneal irregularity that resulted in severe astigmatism. He did not have diplopia. An external eye examination was normal. Internally, his left optic disc had mild diffuse pallor. The Veteran had a visual field defect with contraction of his visual field in the left eye described as 28 degrees up, 45 degrees up nasally, 40 degrees nasally, 45 degrees down nasally, and 45 degrees down with all other quadrants within normal limits. The Veteran did not have a scotoma. His visual field impairment did not result in statutory blindness. The Veteran’s vision loss was attributed to his left optic neuropathy. He did not have any other eye conditions, pertinent physical findings, complications, conditions, signs, or symptoms related to his eye disability. He did not have any scarring or disfigurement attributable to any eye condition. In the prior twelve months, he had not had any incapacitating episodes attributable to any eye condition. The disability did not impact his ability to work. His color vision was 100 percent in the right eye and 70 percent in the left eye. The accompanying visual field perimeter chart showed some loss of visual field slightly different than that recorded in the DBQ, as described below: Meridian Normal Right Eye Left Eye Up 45 33 28 Up temporally 55 50 40 Temporally 85 72 70 Down temporally 85 65 65 Down 65 55 45 Down nasally 50 40 40 Nasally 60 47 40 Up nasally 55 47 40 Total: 500 409 368 Average Concentric Contraction 62.5 51.125 46 An October 2017 VA treatment record notes that the Veteran’s pupils were equally round and reactive. There was no relative afferent papillary defect, disc pallor, or edema. He had normal color vision by Ishihara testing. His visual fields were full to confrontation testing. Based on the above, the Veteran’s left eye disability manifests as decreased color differentiation and visual field loss with average concentric contraction of no less than 36 degrees. As the Veteran is not service connected for a right eye disability, this is rated as a unilateral impairment of visual field and warrants a 10 percent rating. See 38 C.F.R. § 4.79, DC 6080. The Veteran has no other visual impairment as his corrected visual acuity was consistently 20/40 or better, and he has no impairment of muscle function. Similarly, he has had no incapacitating episodes due to his eye disability. There are no rating criteria for color blindness or decreased color differentiation. To the extent that this symptom is inadequately addressed by the rating criteria, the Board has considered whether an extraschedular rating is necessary. In this case, however, the record does not suggest, and the Veteran does not assert, that his decreased color differentiation results in marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). As such, referral to the Director of Compensation Services for extraschedular consideration is not necessary. See Thun, supra. Thus, the Veteran’s left eye optic neuritis does not warrant a disability rating higher than the current 10 percent, and, therefore, his appeal is denied. 4. An increased rating for PTSD The Veteran was originally granted service connection for anxiety disorder not otherwise specified in a July 2010 rating decision. At that time, this disability was rated 10 percent effective July 18, 2009. He appealed that initial rating. An October 2011 decision review officer (DRO) decision increased this initial rating to 50 percent. In November 2011, the Veteran, through his representative, withdrew his appeal on the initial rating for anxiety disorder. The Veteran submitted a claim for an increased rating for his anxiety in August 2013. In a June 2014 rating decision, this disability was recharacterized as PTSD with obsessive compulsive disorder, generalized anxiety disorder not otherwise specified, and depressive disorder not otherwise specified and the Veteran’s claim for an increased rating was denied. During the pendency of this appeal, the Veteran’s rating for PTSD was increased twice. First, the March 2017 DRO decision increased this rating to 70 percent effective November 16, 2015. Then, the January 2018 rating decision increased this rating to 100 percent effective December 1, 2017. This resulted in a staged rating. Below, the Board will address these stages in turn with the exception of the final stage, as the 100 percent rating effective December 1, 2017, represents a complete grant of the benefit sought during that period. The Veteran’s acquired psychiatric disability is currently rated under DC 9411 for PTSD. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. 1. A rating higher than 50 percent for PTSD prior to November 16, 2015 The April 2014 PTSD DBQ shows diagnoses of PTSD, obsessive compulsive disorder, generalized anxiety disorder, and persistent depression. The examiner noted that the Veteran’s symptoms could be differentiated among these diagnoses. As the Veteran’s service-connected disability has been recharacterized to encompass all of these diagnoses, however, this distinction is not necessary. The Veteran’s reported psychiatric symptoms included nightmares, intrusive thoughts and feelings, avoidance of triggers, decreased interest in activities, less interest in socializing with friends and family, counting to avoid anxiety, tension, irregular heartbeat, false trips to emergency room, restlessness, fatigue, irritability, muscle tension, lack of motivation, low energy, loss of interest, weight gain, insomnia, poor concentration, hopelessness, and involuntary suicidal ideation with no intention to follow through. Ultimately, this examiner found occupational and social impairment with reduced reliability and productivity. The Veteran did not have a diagnosis of traumatic brain injury. He was married, but reported increased arguing recently. He got angry easily and had broken a computer and cellphone. His lack of focus impaired his driving, and he had recently been in an accident. He would sometimes go out with his wife, but this decreased as their arguing increased. He had no close friends, stating that he did not return emails or phone calls due to anxiety and lack of motivation to be around others. He did not work, but was a fulltime student. He reported having to work very hard to get his work done due to his trouble concentrating, but his grades were good. The Veteran treated his disability with medication and therapy. He had not been hospitalized. The examiner found symptoms of depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The Veteran did not have any other symptoms attributable to psychiatric disorders. He was casually dressed, cooperative, and oriented. In his July 2014 notice of disagreement, the Veteran reported an increase in psychiatric symptoms and a decrease in the efficacy of his medication. Additionally, he reported that the sexual side effects of his medication were causing increased tension in his marriage, thereby increasing his stress. His lack of sleep, increased panic attacks, and constantly being on guard (hypervigilance) were making his daily life difficult and diminishing his ability to be a good soldier in the Army Reserves. During this period, the Veteran continued to serve as a Reservist. Based on the above, prior to November 16, 2015, the Veteran’s PTSD was manifested by symptoms associated with a 30 percent rating (depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss); symptoms associated with a 50 percent rating (panic attacks, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships) and symptoms associated with a 70 percent rating (suicidal ideation). He also reported hypervigilance, which is not listed with a specific rating. The Board notes that the April 2014 VA DBQ noted the Veteran’s reports of “involuntary suicidal thoughts,” but did not include suicidal ideation among the Veteran’s symptoms. The reason for the distinction between these suicidal thoughts and the symptom of suicidal ideation is not given. As such, applying the benefit of the doubt in the Veteran’s favor, the Board finds suicidal ideation, and therefore a 70 percent rating is warranted prior to November 16, 2015. The Board has also considered whether a higher, 100 percent rating is warranted for this period. The criteria for a 100 percent rating include findings of both total occupational and total social impairment. See 38 C.F.R. § 4.130, DC 9411. This is not shown here. Notably, the Veteran was a full-time student with good grades, a part-time Reservist, and was married. While significant social impairment is shown, the evidence does not support a finding of either total occupational or total social impairment. The Board notes that the Veteran expressed suicidal ideation, which is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran’s suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran specifically denied intent or a plan involving self-harm during the April 2014 VA DBQ. This record does not quantify the frequency of these suicidal thoughts, but the Board notes that the examiner did not include suicidal ideation in the Veteran’s list of applicable symptoms. As such, there is no indication that the Veteran’s self-described “involuntary suicidal thoughts” rise to the level of persistent danger of self-harm. Based on the above, prior to November 16, 2015, the Veteran’s PTSD was consistent with a 70 percent rating, but not higher; to that extent, the appeal is granted. 2. A rating higher than 70 percent for PTSD from November 16, 2015, to December 1, 2017 The November 16, 2015 PTSD DBQ examiner again found occupational and social impairment with reduced reliability and productivity. The Veteran was still married to his wife of four years, but reported arguments. He did not have any children. He denied having friends with whom he socialized. He had completed his associate degree and was still in the Reserves, though he stated that he was in the process of being medically discharged. He worked fulltime for six months and had been recently been switched to the 3pm to 11:30pm shift, which he preferred because of the slower pace. He reported forgetting names at work, but felt that it was excused because he was a veteran. He treated his psychiatric disability with medication, but had not been to counseling since his deployment. He reported anxiety outside in populated areas and in waves at work, but reported that staying busy helped. He reported feeling detached and numb. He had panic attacks three or four times per week. He had chronic sleep problems due to dreams, racing thoughts, and restless legs. He felt depressed and worthless. He had intrusive thoughts of hurting people, self, and things. He would count in Vietnamese to distract himself and twitch his head to clear it of negative thoughts. He felt his concentration issues negatively affected his work. The examiner found symptoms of depressed mood; anxiety; suspiciousness; panic attacks more than once per week; chronic sleep impairment; mild memory loss; flattened affect, circumstantial, circumlocutory, or stereotyped speech; disturbances of motivation and mood; difficulty establishing and maintaining effective work and social relationships; suicidal ideation; and obsessional rituals which interfere with routine activities. The Veteran was cooperative and appropriately dressed and groomed. His speech was normal. He had flattened affect and an anxious mood. His was circumstantial at times. His insight and judgment were good. He endorsed ongoing suicidal and homicidal (nonspecific) ideation without intent. He had no other symptoms attributable to his psychiatric disabilities. He was capable of managing his own financial affairs. An October 2017 VA treatment record includes an assessment for self-harm. The Veteran had recently cut his arms with a knife. He reported fleeting thoughts of suicidal ideation. He denied having an active plan, but said his choice of suicide method would be cutting his wrists and bleeding out. Protective factors were his son and extended family. He adamantly denied homicidal ideation and stated that he would never harm his wife or his eight-month-old son. He felt that cutting served as a distraction from the emotional pain associated with his psychiatric disability and his marital problems. He reported constantly fighting with his wife, which made it difficult to be at home with her. He also stated that he avoided spending time with his infant son because he did not want to fight in front of the baby. He would leave home when stressed and return in the evening. He liked his job and his supervisor was understanding when it came to taking time off for medical appointments. He was on medication and was open to finding a new mental health provider for therapy. He stated that he was not suicidal after talking with this social worker. Additional records from that day note that the Veteran was awake, alert and fully oriented. He was a good historian with normal language function and able to follow examination well. He reported sleeping five or six hours per night and had vivid dreams. A November 2017 VA treatment record notes the Veteran’s concerns of marital stress, an increase in non-suicidal self-injury, and depressed mood. He stated that he began cutting himself in November 2016 in response to difficulty coping with marital stress. He had made “deep” cuts to his hands and legs that had healed without medical attention. His last cut was three months prior. He had a history of punching himself in the face as frequently as once a month and had punched himself once in the prior year. He also reported frequent fighting with his wife, sometimes leading to her punching him in the arm, but he denied ever striking his wife. He had filed for divorce in June 2016, but it was never finalized as his wife became pregnant and their son was born in January 2017. Currently, his wife and son shared one room and he slept in another. She took care of the baby 95 percent of the time and the Veteran only spending five percent of the time with the child, which he attributed to his wife limiting access when he was “in trouble” with her. He began to cut himself in November 2016 in response to stress. He described obsessive behaviors (cutting, counting in Vietnamese, shaking his hands to reorient himself) occurring hourly. He did not endorse compulsions. He worked in human resources at the Portland VA. He stated that he tended to keep to himself at work and beyond. He had no close friends. He reported gaining 50 pounds in the prior two years, which he attributed to stress eating. He endorsed passive suicidal ideation without intent or plan. He denied ever making a suicide attempt, but viewed his cutting as potential preparation for suicide. He stated that he would not kill himself because of his son. He denied any homicidal ideation or attempts. He denied any psychiatric hospitalizations. He reported poor sleep: waking multiple times per night, sweating, and dreams reimagining deployment themes as failure. A mental status examination found him appropriately groomed and professionally dressed. He was alert, cooperative, and able to be redirected. He made appropriate eye contact. His speech was normal in volume and rate, fluent, and clear. His thought processes were coherent, linear, logical, and goal directed. His thought content was depressed. He endorsed suicidal ideation with no acute intent or plan. He denied homicidal ideation. His mood was “down.” His affect was stable, flat, and dysphoric. His cognition was grossly intact. His insight and judgment were fair. On November 17, 2017, the Veteran was hospitalized for inpatient psychiatric treatment. He has subsequently been awarded a 100 percent rating for this disability effective December 1, 2017. Based on the above, from November 16, 2015, to December 1, 2017, the Veteran’s PTSD was manifested by symptoms including suicidal ideation and obsessional rituals which interfere with routine activities, which is consistent with the current 70 percent rating. See 38 C.F.R. § 4.130, DC 9411. He also reported episodes of self-harm (cutting and punching himself). Again, the criteria for a 100 percent rating include “persistent danger of self-harm”; therefore, the question before the Board is whether the Veteran’s suicidal ideation and episodes of self-harm rise to the level of persistent danger of self-harm. In this case, however, the severity, frequency, and duration of the Veteran’s suicidal ideation, cutting, and self-punching have not risen to the level contemplated by the 100 percent disability rating. The Veteran reported a history of punching himself up to once a month. He also reported passive suicidal ideation and a nine-month period of cutting (November 2016 to August 2017) without providing a frequency of either. The Veteran reported hourly obsessive rituals including cutting, counting in Vietnamese, and shaking his hands to reorient himself, and in doing so equating his cuts with obsessive rituals, not self-harm. He also specifically stated that he had never made a suicide attempt and would not do so because of his son. As such, there is no indication that the Veteran’s self-described suicidal ideation or episodes of self-harm rise to the level of persistent danger of self-harm based on frequency and/or severity. The Board finds that the level of impairment caused by the Veteran’s symptoms more closely approximates the level associated with the assigned 70 percent rating. The Veteran experiences occupational and social impairment with reduced reliability and productivity with deficiencies in most areas. A higher (100 percent rating) would require total occupational and social impairment, which is not shown here. Notably, the Veteran was employed full-time student during this period, which weighs strongly against a finding of total occupational impairment. He reported significant interpersonal difficulties, particularly with his wife, but there is no showing of either total occupational or total social impairment. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 100 percent rating for the noted period. The criteria for a 100 percent or higher rating are not met, and the appeal must be denied. As a final matter, the Board finds that this appeal does not raise a claim for a total disability evaluation based upon individual unemployability (TDIU), or any other downstream issues. The Veteran did apply for TDIU in December 2017, but he also reported that he stopped working full-time in November 2017. As indicated above, a 100 percent evaluation has been in effect for PTSD since December 1, 2017; a combined 100 percent evaluation for multiple service-connected disabilities has been in effect since November 16, 2015; and he has also been awarded special monthly compensation on the basis of PTSD and other service-connected disabilities independently ratable at 60 percent or more from December 1, 2017. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Houbeck The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.