Citation Nr: 21063112 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 18-20 710 DATE: October 13, 2021 ORDER As new and material evidence has been received, the claim of entitlement to service connection for right knee disability is reopened; the appeal is granted to this extent only. As new and material evidence has been received, the claim of entitlement to service connection for left knee disability is reopened; the appeal is granted to this extent only. As new and material evidence has been received, the claim of entitlement to service connection for obstructive sleep apnea is reopened; the appeal is granted to this extent only. Entitlement to service connection for obstructive sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is denied. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for left knee disability is remanded. Entitlement to a rating in excess of 10 percent for degenerative disc disease (DDD) of the lumbar spine is remanded. Entitlement to a rating in excess of 20 percent for degenerative arthritis of the cervical spine is remanded. FINDINGS OF FACT 1. A March 2007 rating decision denied service connection for right and left knee disability. 2. The evidence received since the March 2007 rating decision is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for left and right knee disability. 3. A March 2008 rating decision denied service connection for sleep apnea. 4. The evidence received since the March 2008 rating decision is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for sleep apnea. 5. The Veteran's obstructive sleep apnea was not incurred in or caused by his period of active service; nor was it caused by his service-connected PTSD. 6. Throughout the entire period on appeal, the Veteran's PTSD has not resulted in symptoms of a greater severity than occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for right knee disability. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 2. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for left knee disability. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 3. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for obstructive sleep apnea. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 4. The criteria for service connection, to include on a secondary basis, for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had a period of active duty for training (ACDUTRA) from May 1990 to December 1990 and active service from June 2004 to April 2005. The Veteran also had Reserve service. These matters come to the Board of Veterans' Appeals (Board) on appeal from December 2016 and April 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted additional evidence, in the form of medical treatment records, after the January 2018 statement of the case (SOC). A waiver of initial RO review of additional evidence submitted by an appellant is automatic in substantive appeals filed after February 2, 2013, unless the claimant or claimant's representative requests in writing that the RO initially review such evidence. See 38 U.S.C. § 7105(e). This applies even to situations where the case had not been certified to the Board at the time the evidence was received, as the amended statute supersedes 38 C.F.R. § 19.31. As the Veteran's substantive appeal was submitted in March 2018, and he did not explicitly ask for RO review of the new evidence, no waiver is necessary, and the Board shall consider the newly submitted evidence in the first instance. New and Material Evidence A rating action from which an appeal is not perfected becomes final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing, and after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. In order to reopen a claim which has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is 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 which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether that low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. As new and material evidence has been received, the claim of entitlement to service connection for a right and left knee disability is reopened; the appeals are granted to this extent only. The issues of entitlement to service connection for a right and left knee disability were initially denied in a September 2006 rating decision. The Veteran was notified of the rating decision and requested reconsideration of these issues in October 2006. In a March 2007 rating decision, the RO again denied service connection for a right and left knee disability, indicating that the evidence did not demonstrate a current right or left knee disability. The evidence of record included service treatment records (STRs) and post-service treatment records, noting complaints of bilateral knee pain. The Veteran was notified of the rating decision in March 2007. However, the Veteran took no further action with regard to these issues. Therefore, the March 2007 decision denying service connection for a right and left knee disability is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.156(b), 3.160(d), 20.302, 20.1103. Since the March 2007 rating decision became final, in pertinent part, the Veteran received a diagnosis of mild degenerative joint disease of the bilateral knees. The Board finds that the low threshold requirement for new and material evidence is satisfied with respect to the Veteran's claims. Shade v. Shinseki, 24 Vet. App. 110 (2010). When considering the new evidence in conjunction with the evidence already of record, it raises a reasonable possibility of substantiating the claims. Thus, the Board finds that new and material evidence has been submitted and the petition to reopen the claims of entitlement to service connection for a right and left knee disability must be granted. As new and material evidence has been received, the claim of entitlement to service connection for sleep apnea is reopened; the appeal is granted to this extent only. In a March 2008 rating decision, the RO denied service connection for sleep apnea, indicating that, although the Veteran received a diagnosis of sleep apnea in August 2007, the evidence did not demonstrate that his sleep apnea was incurred in or caused by active service. The evidence of record included service treatment records (STRs) and post-service treatment records. The Veteran was notified of the rating decision in March 2008 and timely filed a Notice of Disagreement (NOD). However, following the issuance of the SOC, the Veteran took no further action. Therefore, the March 2008 decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.156(b), 3.160(d), 20.302, 20.1103. Since the March 2008 rating decision became final, in pertinent part, the Veteran raised a new theory of entitlement, namely that his sleep apnea was secondary to his service-connected PTSD. In support of his contention, he submitted medical articles suggesting that sleep apnea may be related to PTSD, as well as a medical opinion indicating that his sleep apnea is more likely than not related to his PTSD and nightmares. The Board finds that the low threshold requirement for new and material evidence is satisfied with respect to the Veteran's claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). When considering the new evidence in conjunction with the evidence already of record, it raises a reasonable possibility of substantiating the claim. Thus, the Board finds that new and material evidence has been submitted and the petition to reopen the claim of entitlement to service connection for obstructive sleep apnea must be granted. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In addition, certain chronic diseases may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1131; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis. In this instance, the evidence must demonstrate an etiological relationship between a service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. 38 C.F.R. § 3.310(a); Wallin v. West, 11 Vet. App. 509 (1998). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Entitlement to service connection for obstructive sleep apnea, to include as secondary to PTSD, is denied. The Veteran contends that he is entitled to service connection for obstructive sleep apnea, to include as secondary to his service-connected PTSD. Notably, the Veteran initially claimed that his sleep apnea was due to exposure to certain burn pit smokes during his service in Iraq; however, after his claim was denied and the decision became final, the Veteran submitted a claim to reopen entitlement to service connection on a secondary theory of entitlement, claiming that his sleep apnea was due to his service-connected PTSD. No further evidence or claims were made regarding his Gulf War service. Thus, the Board finds that the Veteran has abandoned the theory of entitlement that he should be service connected for sleep apnea as due to his exposure to burn pits during his Gulf War service. Service treatment records (STRs) are silent for any complaints, treatment, or diagnosis for a sleep disorder or related symptoms, including his January 1990 enlistment examination and a May 2004 examination. Notably, a March 2005 post-deployment assessment indicates that he denied experiencing any difficulty breathing or feeling tired after sleeping during or since his deployment. Medical treatment records reflect that the Veteran received a diagnosis of sleep apnea in August 2007. Early mental health treatment records additionally note symptoms of difficulty sleeping, and a later, December 2016 mental health record indicates that his sleep apnea was likely contributing to his PTSD. The Veteran's July 2007 and February 2017 PTSD VA examinations note that the Veteran had sleep disturbances. The July 2007 PTSD examination indicates that some of his difficulty sleeping may be due to sleep apnea but notes that the Veteran had yet to undergo a sleep study. The February 2017 examination, which occurred after he was diagnosed with sleep apnea, is silent for any mention of sleep apnea. A statement from the Veteran, received in June 2008, indicates, in pertinent part, that shortly after his return from Iraq, his girlfriend told him that he snored and sometimes stopped breathing. In September 2016, the Veteran submitted medical articles suggesting a relationship between sleep apnea and PTSD. Specifically, one article indicates that increases in sleep disturbances in redeployed military personnel is potentially related to PTSD, depression, anxiety, or TBI; the study notably indicates, however, that it remains unclear if their sleep complaints are solely an epiphenomenon of comorbid illnesses, persistent maladaptive sleep practices that occur during deployment, or an independent diagnosis. A second article notes an association between sleep apnea and PTSD, concluding that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries, and patients with psychiatric disorders and coincident symptoms suggesting sleep-disordered breathing should be evaluated for sleep apnea. A third article concludes that comorbid insomnia and obstructive sleep apnea is a frequent diagnosis in military personnel referred for evaluation of sleep disturbances after deployment. Additionally, in December 2016, the Veteran submitted a May 2013 Board decision, which granted entitlement to service connection for sleep apnea as secondary to PTSD. In pertinent part, the Board awarded service connection because the appellant in that case received treatment for sleep disorder-type symptoms, diagnosed as upper airway resistance syndrome, within a few months of his separation from service, and a subsequent VA medical opinion found that the appellant described a sleep disorder that may be more related to psychological, citing to medical literature, and indicated that his upper airway resistance syndrome would likely develop into sleep apnea. The Veteran was afforded a VA examination in December 2016. The examination notes a diagnosis of obstructive sleep apnea. The Veteran described the onset of his claimed sleep apnea, indicating that his girlfriend at the time told him that he snored and stopped breathing. The Veteran indicated that he had a sleep study done and he started treatment with a CPAP machine. The Veteran reported that, since beginning his treatment, his nightmares decreased, he began sleeping better, and he felt more rested. The examiner noted review of the Veteran's records, including his medical treatment records, lay statements, and the articles provided by the Veteran. The examiner opined that the Veteran's sleep apnea was less likely than not proximately due to or the result of PTSD. The examiner, specifically discussing medical literature, indicated that PTSD is not shown to cause obstructive sleep apnea. A June 2018 private medical treatment record notes that the Veteran's sleep was improving with his use of CPAP therapy, but he continued to have nightmares. The provider opined that the Veteran's sleep apnea is more likely than not related to his PTSD and nightmares. No explanation or supporting rationale was provided. After a review of the evidence of record, the Board finds the weight of the evidence is against the claim for service-connection for obstructive sleep apnea on either a direct or secondary basis. Regarding the theory of direct service connection, there is no competent evidence that a sleep disorder was incurred during the Veteran's period of active duty or manifested to a compensable degree within one year of separation. Even when considering the Veteran's reports of onset of sleep problems that he claims were relayed to him by his girlfriend, the Board finds that these statements do not avail the Veteran as the Veteran indicated that she made this observation after this period of active service. Additionally, the Veteran did not report any symptoms on his March 2005 post-deployment assessment which could be attributable to a sleep disorder. Moreover, prior to the July 2007 VA examiner's statement that some of the Veteran's symptoms "may" be related to sleep apnea, there is no mention of any sleep related symptoms other than in the context of his mental health disorder. Thus, the earliest medical evidence of record indicating treatment for sleep apnea is more than two years after his period of active service. Accordingly, service connection for obstructive sleep apnea cannot be granted on a direct basis based on in-service incurrence or on a presumptive basis for chronic diseases. 38 C.F.R. §§ 3.307, 3.309. Although the Veteran and his former girlfriend are competent to report his symptoms, to the extent that such assertions purport to establish a diagnosis or etiology of any such disability, such assertions do not provide persuasive support for the claim, as neither is not shown to possess the medical training to render competent opinions about such complex medical matters. See Davidson, 581 F. 3d at 1313; Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Furthermore, there is no probative medical opinion of record indicating that his obstructive sleep apnea is related to his active service. In this regard, the Board acknowledges that a VA medical opinion has not been obtained addressing whether the Veteran's sleep apnea was incurred in or caused by his active service. However, the Board finds that a remand for an opinion is not necessary because, as addressed above, the Board notes that the record does not establish that an event, injury, or disease occurred in service or that his sleep apnea manifested during an applicable presumptive period. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006); Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). Accordingly, the Board finds that the preponderance of the evidence is against a grant of service connection for sleep apnea on a direct basis. Turning to the theory of secondary service-connection, the Board finds the December 2016 VA examiner's opinion to be the most probative evidence of record. The examiner considered medical literature suggesting a relationship between PTSD and sleep apnea, the Veteran's medical treatment records, as well as his reports of onset and history, but nevertheless found that it was less likely than not that the Veteran's sleep apnea was proximately due to or the result of PTSD. The Board finds the examination and opinion is both adequate and probative evidence of record for purposes of deciding the claim. The Board has considered the private medical opinion indicating that the Veteran's sleep apnea is more likely than not related to his PTSD and nightmares. However, a medical opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record; bare conclusions, even those made by medical professionals, which are not accompanied by a factual predicate in the record, are not probative medical opinions). Thus, the Board finds that the private opinion is outweighed by the opinion of the VA examiner. The Board has considered the medical articles noting a possible relationship between obstructive sleep apnea and PTSD. Medical treatise evidence can, in some circumstances, constitute competent medical evidence, especially when combined with an opinion of a medical professional. See Sacks v. West, 11 Vet. App. 314, 317 (1998); see also 38 C.F.R. § 3.159(a)(1). However, generic information in a medical journal or treatise is normally too general and inconclusive to constitute the sole basis for establishing a medical nexus to a disease or injury. Mattern v. West, 12 Vet. App. 222, 227 (1999). In this case, the submitted articles are general in nature and do not specifically state a correlation between obstructive sleep apnea and PTSD and have not been specifically related to the Veteran by a medical professional. Thus, these treatises cannot serve as medical nexus evidence between the Veteran's sleep apnea and PTSD. Furthermore, the Board notes that these articles were considered by the December 2016 VA examiner, who found that the articles did not establish causation of obstructive sleep apnea by PTSD. Thus, the Board finds that the probative value of these medical articles is outweighed by the opinion of the VA examiner. The Board has also considered the prior Board decision submitted in support of the Veteran's claim. The Board notes that prior decisions are not precedential, and "previously issued Board decisions will be considered binding only with regard to the specific case decided." 38 C.F.R. § 20.1303. "Each case presented to the Board will be decided on the basis of the individual facts of the case." Id. In this regard, the Board notes that the cited prior Board decision based its decision, in part, on an intermediate diagnosis of upper airway resistance syndrome, diagnosed within a few months of his separation from service, which was later found to lead to sleep apnea. The Board finds the present ase is distinguishable from the one cited because the Veteran did not receive any treatment or diagnosis for a sleep disorder, separate from the symptoms of his mental health disorder, until years after his separation from active service. Therefore, the Board does not find that this May 2013 Board decision provides persuasive support for the Veteran's claim. The Board has considered the Veteran's contention that his sleep apnea was caused by his service-connected PTSD. While the Board acknowledges that the Veteran is competent to report his symptoms, the Board notes that the matter of the etiology of obstructive sleep apnea is one within the province of trained professionals. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the etiology of obstructive sleep apnea is a complex medical matter that falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). As the Veteran is not shown to be other than a layperson without the appropriate training and expertise, he is not competent to render a probative opinion regarding the medical matter upon which this claim turns. Id. Thus, the probative value of the examiner's opinion outweighs that of the Veteran, as the examiner has more education, experience and training in determining the etiology of obstructive sleep apnea. For these reasons, the Board finds that the preponderance of the evidence is against a grant of service connection on a direct or secondary basis for obstructive sleep apnea. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. 38 U.S.C. § 5107(b). INCREASED RATING Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Court has held that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" rating. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (the Court noted a distinction between claims stemming from an original rating versus increased rating). See also Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings). Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. The Veteran is currently in receipt of a 50 percent disability rating for his service-connected PTSD pursuant to Diagnostic Code 9411. He contends that he is entitled to a higher disability rating. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A 50 percent evaluation is warranted if the evidence establishes there is occupational and social impairment, with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work or social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted 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; memory loss for names of close relatives, own occupation, or own name. Id. The criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, the Veteran must demonstrate the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). A December 2016 VA treatment record notes that the Veteran presented for his appointment alone to discuss an incident at work. Specifically, he indicated that, while sitting next to another employee, a third employee came up behind him and slammed a hard plastic bin down; he reported that he thought it was an explosion and, recalling his time in service, ducked, reached across with his left hand, and threw the object to his left as hard as he could. The employee next to him was directly in the path of the redirected bin and suffered laceration injuries to her forehead and nose. He indicated that he regained control immediately when the third employee noted that the second employee was bleeding. The Veteran indicated that he felt terrible and had a hard time concentrating the rest of the day. The Veteran further indicated that this type of occurrence had never happened at work before. The record notes that the Veteran had adequate grooming and hygiene. He was cooperative, and his speech was normal. There was no psychomotor agitation or slowing noted. His mannerisms were normal. His affect was noted as mildly restricted, congruent, and appropriate. His thought process was linear, logical, and goal directed. He did not endorse suicidal ideation, homicidal ideation, hallucinations, or delusions. He was alert and oriented, and his memory, attention, and concentration were grossly intact. Insight and judgement were noted as moderate to good. A February 2017 VA treatment record notes that the Veteran indicated that he had difficulty concentrating since his work incident, always worried that someone was coming to get him. He reported that he was not able to use elevators or go to grocery stores. He also indicated that he was too nervous to drive now. He reported that he was unable to sleep more than one and a half hours before his medication stopped working and the nightmares started. He indicated that he was moved to another department at work cleaning IV pumps, and he was anticipating punishment from HR regarding the incident at work. The record notes that the Veteran was increasingly frustrated by his workplace environment issues. The evaluator indicated that the Veteran reported a recent exacerbation by an event at work; he had increased nightmares and anxiety/arousal during the day. The Veteran was afforded a VA examination in February 2017, which provides a diagnosis of PTSD. The examination notes that the Veteran had symptoms of depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; impairment of short- and long-term memory; and difficulty establishing and maintaining effective work and social relationships. Additionally, the Veteran described a work incident in which he was startled by a loud noise and he reacted by throwing a piece of equipment that injured a coworker. The examiner indicated that the Veteran was alert, oriented, cooperative, and verbal. He was appropriately dressed with adequate hygiene and grooming. His psychomotor activity was within normal limits. His speech was organized, goal directed, and adequate for communication. His mood and affect were congruous and within normal limits. He had no current suicidal ideation, homicidal ideation, auditory hallucinations, and no previous suicide attempts. His appetite was inconsistent, and his weight fluctuated. He had problems getting to sleep; his sleep was frequently disrupted by nightmares and noises in his house. There were limitations in memory and concentration observed. The Veteran was capable of managing his financial affairs. The examiner opined that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. An October 2017 mental health assessment for the Caregiver Program notes that the Veteran reported disturbed sleep due to trying to get used to a new CPAP mask, an increase in stress related to the death of his girlfriend's mother, a change in work schedule, and trying new medications. The Veteran had not been hospitalized in the last 90 days; he had one missed appointment, which was rescheduled one week later. He denied any concern for personal safety. After a review of the evidence, the Board finds that a rating in excess of 50 percent is not warranted at any time during the period on appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In this regard, the Board concludes that the weight of the evidence does not demonstrate that the Veteran's symptoms result in occupational and social impairment greater than an occupational and social impairment with reduced reliability and productivity. In this regard, the Board finds that the probative evidence of record reflects that the Veteran suffers from symptoms of depressed mood; anxiety; panic attacks more than once a week; chronic sleep impairment; nightmares; impairment of short- and long-term memory; difficulty establishing and maintaining effective work and social relationships; exaggerated startle; difficulty concentrating; and hypervigilance due to his service-connected PTSD. The Board finds that these symptoms are appropriately contemplated under the currently assigned 50 percent disability rating. The Board notes that the evidence consistently reflects no significant impairment in speech, judgment, or thinking. He was noted as being able to handle his own financial affairs. He was oriented and consistently denied delusions, hallucinations, suicidal ideation, and homicidal ideation. Moreover, the record does not show any episodes of neglect of personal hygiene or disorientation, which is contemplated in the rating criteria for a higher disability rating. Indeed, the evidence throughout the period on appeal has consistently indicated that the Veteran was alert, oriented, cooperative, was appropriately dressed with adequate grooming and hygiene. His speech was within normal limits; his thoughts were logical, and goal oriented. His insight and judgement were noted as moderate to good. Further, although his position at work changed, the evidence indicates that the Veteran was employed during the period on appeal. Although the Board recognizes that the evidence reflects that the Veteran had an incident at work which resulted in the Veteran injuring a coworker, the Board does not find that this incident rises to the level of occupational or social impairment warranting a higher disability rating. First, the Board notes that the evidence does not reflect, and the Veteran does not contend, that this type of incident has occurred more than once. Thus, the Board finds that, even if this could be considered, for example, impaired impulse control or being a danger to others, this single report of such symptoms without any further explanation regarding the frequency, severity, duration, or impact on his functioning does not rise to the level which warrant a higher evaluation. Additionally, the Board notes that the Veteran described this incident at his February 2017 VA examination and the examiner reviewed the medical treatment records that documented the Veteran's reports regarding this incident, and the examiner nevertheless found that the Veteran had no more than occupational and social impairment with reduced reliability, which does not support a rating in excess of 50 percent. The examination report reflects a thorough interview regarding his current symptoms, and the opinion rendered is not inconsistent with the Veteran's reports of his symptoms. Therefore, the Board finds the examination and opinion is adequate and probative evidence of record in this regard. Finally, to the extent that the record reflects that the Veteran experienced an increase in symptoms following the incident at work, including increased anxiety, nightmares, and difficulty driving, the Board does not find that these symptoms are reflective of his PTSD disability picture as a whole. Specifically, the Veteran's medical treatment records indicate that his symptoms were exacerbated by the work event, and as noted above, there is no indication that an event like the one reported occurred at any other time. Nevertheless, even with the increase in his symptoms, the Board does not find that his symptoms were of such severity as to be considered occupational and social impairment with deficiencies in most areas or total occupational and social impairment. Indeed, despite the Veteran's reported increase in symptoms, the Veteran continued to work and there is simply no other evidence to indicate how these increased symptoms impacted his occupational and social functioning. Accordingly, the Board finds that the Veteran's disability picture is contemplated by the Rating Schedule and adequately reflected in his currently assigned ratings. The Board acknowledges that the Veteran's PTSD symptoms impact his occupational and social functioning, and it is because of these symptoms that the Veteran is in receipt of a 50 percent rating throughout the entire period on appeal. For the reasons set forth above, however, the Board finds that the Veteran's degree of occupational and social impairment does not approximate the symptoms associated with occupational and social impairment with deficiencies in most areas or total occupational and social impairment. Accordingly, the Board finds that the weight of the evidence is against the assignment of a rating greater than 50 percent at any time during the period on appeal for his service-connected PTSD. 38 U.S.C. § 5107(b); Gilbert v. Derwinski,1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to service connection for a bilateral knee disability is remanded. The Veteran contends that his bilateral knee disorders are due to his active service. VA's duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d). VA is obligated to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As previously indicated, the Veteran has received a diagnosis of mild degenerative joint disease of the bilateral knees. He contends that he has experienced bilateral knee pain since service, and in September 2016, he submitted several articles suggesting a relationship between arthritis and the demands of military service. The Board finds that the articles and lay evidence are not sufficient, in themselves, to render a decision in this case; although the Board makes no determination, expressed or implied, as to the credibility of any statements on file, as the Veteran has not been afforded a VA examination for his bilateral knee disorder, the Board finds that a VA examination and opinion is warranted to determine whether the Veteran's bilateral knee disorder is etiologically related to active service. Entitlement to a rating in excess of 10 percent for degenerative disc disease (DDD) of the lumbar spine and entitlement to a rating in excess of 20 percent for degenerative arthritis of the cervical spine is remanded. The Board recognizes that in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court emphasized that case law and VA guidelines anticipate that VA examiners will offer opinions on the severity of flare-ups based on estimates derived from information procured from relevant sources, including lay statements of the Veteran. On the most recent VA back examination in October 2016, the Veteran endorsed flare-ups described as feeling as though his back tightened up more than before; he indicated that he had functional loss which was also described as feeling as though his back tightened up more than before. The examiner was unable to say without resorting to merely speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or during flare-ups because the Veteran was not actively experiencing a flare-up at the time of the examination. The Veteran was also afforded a VA neck examination in October 2016 which notes that he endorsed flare-ups of the cervical spine, described as increased pain at the end of the day, rated as a 7 out of 10. The Veteran did not report having any functional loss or functional impairment of the cervical spine; however, the examiner indicated that the Veteran's cervical spine disorder could, in part, negatively impact his ability to lift, carry, push, or work overhead due to pain and decreased range of motion. The examiner nevertheless indicated that she was unable to say without resorting to merely speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or during flare-ups because the Veteran was not actively experiencing a flare-up at the time of the examination. When a VA medical examination is not conducted during a flare-up or following repeated use over time, it must include an estimate of functional ability then based on all procurable information or explain why such an estimate cannot be provided. Sharp v. Shulkin, 29 Vet. App. 26, 33-35 (2017). All procurable information includes that from the Veteran regarding the severity, frequency, duration, precipitating and alleviating factors, and the extent his functional ability is limited. In this regard, the Board notes that some of this information was elicited from the Veteran at each examination here, although it was seemingly not considered by the examiner. Thus, the VA medical examinations are inadequate in this regard, and a remand is necessary so new examinations can be scheduled. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any currently present right and left knee disability. The electronic claims file must be made accessible to the examiner for review in conjunction with the examinations. (a.) The examiner should opine as to whether it is at least as likely as not (50 percent or better probability) that any right and/or left knee disability had its initial onset in service or is otherwise etiologically related to the Veteran's active service. (b.) In making this determination, the examiner must consider all of the relevant medical and lay evidence of record. An explanation for all opinions expressed must be provided. 2. Schedule the Veteran for VA medical examination to determine the current severity of his service-connected lumbar and cervical spine disabilities. The claims file must be reviewed by the examiner(s). (Continued on the next page) The examiner must test the Veteran's movements of the lumbar spine and cervical spine that are painful on active use, passive use, in weight-bearing, and non-weight-bearing. To the extent possible the examiner also must estimate any additional functional loss caused by the Veteran's flare-ups. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or a deficiency in the record (additional facts are required). Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Hite, Associate Counsel 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.