Citation Nr: 21067536 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 13-33 736A DATE: November 4, 2021 ORDER 1. A 70 percent rating for posttraumatic stress disorder is granted throughout from August 20, 2009, subject to regulations governing payment of monetary awards. 2. Entitlement to a rating in excess of 10 percent for a right knee disability (under Code 5010) prior to March 30, 2015 is denied; from that date, a 20 percent combined (10 percent under Code 5010 and 10 percent under Code 5257) rating is granted for the right knee disability, subject to the regulations governing payment of monetary awards. 3. Entitlement to a rating in excess of 10 percent for a left knee disability (under Code 5010) prior to March 30, 2015 is denied; from that date, a 20 percent combined (10 percent under Code 5010 and 10 percent under Code 5257) rating is granted for the left knee disability, subject to the regulations governing payment of monetary awards. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted from [the earlier effective date of] October 1, 2009, subject to the regulations governing payment of monetary awards. FINDINGS OF FACT 1. Throughout, the Veteran's PTSD disability picture is best characterized as occupational and social impairment with deficiencies in most areas; total occupational and social impairment due to PTSD is not shown. 2. Prior to March 30, 2015, the Veteran's right knee disability was manifested by functional loss due to pain, but was not shown to be manifested by compensable limitations of flexion or extension or by subluxation or instability; from that date, the right knee disability is reasonably shown to have been manifested by arthritis with painful motion (but with limitations of flexion and extension to less than a compensable degree), and by slight, but not greater, instability. 3. Prior to March 30, 2015, the Veteran's left knee disability was manifested by functional loss due to pain, but was not shown to be manifested by compensable limitations of flexion or extension or by subluxation or instability; from that date, the left knee disability is reasonably shown to have been manifested by arthritis with painful motion (but with limitations of flexion and extension to less than a compensable degree), and by slight, but not greater, instability. 4. From October 1, 2009, the Veteran's service-connected disabilities: PTSD (rated 70 percent) and hemorrhoids (rated 0 percent) are reasonably shown to have rendered him unable to maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The Veteran's PTSD warrants a 70 percent (but no higher) rating, throughout, from August 20, 2009. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130, Diagnostic Code (Code) 9411. 2. A rating in excess of 10 percent for the Veteran's right knee disability is not warranted prior to March 30, 2015; from that date the right knee disability warrants a combined 20 percent, but no higher, rating (based on formulation of 10 percent under Code 5010 and 10 percent under Code 5257). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.59, 4.71a; Codes 5010, 5257. 3. A rating in excess of 10 percent for the Veteran's left knee disability is not warranted prior to March 30, 2015; from that date the left knee disability warrants a combined 20 percent, but no higher, rating (based on formulation of 10 percent under Code 5010 and 10 percent under Code 5257). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.59, 4.71a; Codes 5010, 5257. 4. From October 1, 2009, the schedular criteria for a TDIU rating are met; a TDIU rating is warranted. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from October 1967 to October 1969. This matter is before the Board of Veterans' Appeals (Board) on remand from the U.S. Court of Appeals for Veterans Claims (CAVC). The matter was initially before the Board on appeal of an August 2011 rating decision (that granted service connection for right and left knee strain, rated 0 percent, each, effective April 16, 2010, and an October 2013 rating decision that granted service connection for PTSD, rated 30 percent from August 20, 2009, 50 percent from July 6, 2011, and 70 percent from May 21, 2013. An interim ( August 2013 ) rating decision increased the ratings for right and left knees to 10 percent, each, effective March 22, 2013. A May 2015 rating decision granted the Veteran a total disability rating based on individual unemployability, effective May 21, 2013. In October 2017, a Travel Board hearing was held before the undersigned. At the hearing it was clarified, with respect to psychiatric disability, that what the Veteran is seeking is an effective date prior to May 21, 2013 for the award of a 70 percent rating. An additional interim ( May 2019 ) rating decision increased the ratings for the knee disabilities to 10 percent, each, throughout, effective April 16, 2010. In January 2018, these matters were remanded for further development. An October 2019 Board decision denied entitlement to service connection for bilateral hearing loss, entitlement to ratings in excess of 10 percent for right and left knee strain, and entitlement to ratings for PTSD in excess of 30 percent prior to July 6, 2011 and in excess of 50 percent from that date to May 21, 2013. The Veteran appealed that decision to the CAVC. A March 2021 CAVC Memorandum Decision vacated the portion of the Board's October 2019 decision that denied entitlement to ratings in excess of 10 percent for right and left knee strain, and entitlement to ratings for PTSD in excess of 30 percent prior to July 6, 2011 and in excess of 50 percent from that date to May 21, 2013 and remanded those issues to the Board for further development and re-adjudication. [The CAVC left undisturbed the part of the Board decision that denied entitlement to service connection for bilateral hearing loss because the Veteran failed to raise any argument about the Board's denial of his claim seeking service connection for bilateral hearing loss, and such appeal was considered abandoned.] The March 2021 CAVC Memorandum Decision noted multiple errors. Regarding the rating for PTSD, it was noted that the Veteran's private and VA medical records show that he presented several symptoms contemplated in the 70 percent rating category, such as obsessional rituals that interfere with routine activities, impaired impulse control, inability to establish and maintain effective relationships, intermittent illogical speech, and near-continuous panic or depression affecting the ability to function. Some of his symptoms also manifested in more severe types as contemplated in the 100 percent category, which includes hallucinations. The Board failed to meaningfully discuss this evidence or explain how it supports the disability rating assigned. On remand, the Board was directed to consider these symptoms in assessing the appropriate rating for the Veteran's PTSD. Regarding separate instability ratings for right and left knee disabilities, the CAVC noted that unlike knee strain, knee instability under Code 5257 generally requires a claimant to demonstrate a ligament tear or the use of an assistive device for ambulation. In its decision, the Board summarized knee examination reports and principally focused on flexion of the knee, without analyzing other symptoms related to the Veteran's knees. Specifically, the Board failed to address his lay statements and medical reports noting difficulty walking, regular use of a cane and brace, and occasional loss of balance because his left knee gives out. The Board was directed to ensure that its balancing of the evidence is not skewed by favoring objective medical evidence of instability over related lay statements. The CAVC Memorandum also directed the Board to address the Veteran's claim for TDIU for the period before May 2013 and carefully consider the holding in Harper v. Wilkie, 30 Vet.App. 356, 359 (2018) when determining an appropriate effective date for his reward for TDIU during the appeal period. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Reasonable doubt regarding the degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. Functional impairment is to be assessed on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity. 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When the appeal is from the initial rating assigned with a grant of service connection, (as with the PTSD and right and left knee rating claims) the severity of the disability during the entire period from the grant of service connection to the present is to be considered. "Staged" ratings may be assigned for distinct periods when different levels of impairment are shown. Fenderson v. West, 12 Vet. App. 119 (1999). 1. A 70 percent rating for posttraumatic stress disorder is granted throughout from August 20, 2009, subject to regulations governing payment of monetary awards. The Veteran's PTSD has been assigned staged ratings of 30 percent prior to July 6, 2011 and in excess of 50 percent from that date to May 21, 2013, under the General Rating Formula for Mental Disorders (General Rating Formula), which provides that: a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted where 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 and social relationships. A 70 percent rating is warranted where there is 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. 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 (ADLs) (including maintenance of minimal personal hygiene);disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. §4.130, Code 9411. Ratings for psychiatric disability are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment from a psychiatric disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms listed in the General Rating Formula. Instead, VA must consider all symptoms of a claimant's condition that affect occupational and social function. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. §4.126(a). When evaluating the level of disability from a mental disorder, the rating agency 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). The Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994 (DSM-IV)) at 32. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). [Under a revision to the governing criteria during the evaluation period, VA's use of DSM-IV has been superseded by the new DSM-V, which does not incorporate use of the GAF scale to reflect severity of psychiatric disability. As the Veteran's claim arose when the prior criteria were in effect, GAF scores may be considered as evidence bearing on the severity of the disability. 38 C.F.R. §4.126 (a).] When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. §4.7. After careful consideration of the evidence, reasonable doubt remaining, including regarding degree of disability, is to be resolved in favor of the Veteran. 38 U.S.C. §5107; 38 C.F.R. §§3.102, 4.3. In a February 2010 private psychiatric evaluation, the Veteran reported that he had been married for 20 years, had difficulty sleeping, and was hyperalert (constantly checking his surroundings). He related that he had nightmares due to trauma he experienced in Vietnam, was always on edge, was depressed, and had thoughts of suicide, but had not attempted suicide. The Veteran reported that he occasionally felt helpless, but not hopeless, and that although he enjoyed dancing (and found peace dancing), he experienced anger outbursts and tended to isolate. He related that he had attended group therapy at the Vet Center, had not been hospitalized for psychiatric symptoms, and retired in September 2009 after 41 years with the post office. On mental status examination, it was noted that the Veteran was dressed appropriately, had no psychomotor agitation, his speech was slightly pressured, and although his thought processing was circumstantial and rambling, he was easily redirectable. His mood was mildly dysphoric, his affect was appropriate to his mood, his insight and judgment were good, and he was oriented in all spheres. The Veteran's memory was good, and he reported no anhedonia or homicidal ideation. The provider noted PTSD symptoms of hypervigilance, isolation, nightmares, and anger outbursts, and PTSD was diagnosed. A GAF score of 60 was assigned. The provider indicated that the Veteran needed psychotherapy and should continue group therapy. A May 2010 private treatment record notes that the Veteran reported difficulty sleeping, flashbacks related to his military service, and some anxiety and nervousness. He reported no suicidal or homicidal ideation and that he still attended VA group therapy. A June 2010 private treatment record notes that the Veteran reported difficulty with sleep, hypervigilance, and no suicidal or homicidal ideation. On July 2010 VA PTSD examination, the Veteran reported no suicidal or homicidal ideation in the last 30 days, that he has been in treatment at the Oak Lawn Vet Center since 2009, and that he has felt depressed "on and off" for many years. He related that he had difficulty falling and staying asleep, experienced nightmares and flashbacks related to his duties as a combat medic in Vietnam, and experienced anger, avoidance, and irritability. The Veteran denied any significant depression, significant use of alcohol, and anhedonia. He related that he had fair energy, concentration, and appetite. On mental status examination, the Veteran was oriented in all spheres, his speech had normal rate and rhythm, he reported no hallucinations, his thought process was normal, and his insight and judgment were good. A GAF score of 45 was assigned. A July 2010 VA treatment record notes that the Veteran reported difficulty initiating sleep and decreased energy and appetite, and he denied anhedonia and suicidal ideation, intent, or plan. He related that he occasionally drank beer with friends, but had some decreased interest in socializing. The Veteran reported verbal outbursts in response to a perceived threat, that he sat alone in his basement if his wife was at treatment, that he becomes startled by the slightest noise, that he will watch TV with his handgun at his side, and that he attended church sporadically. On mental status examination, the Veteran had good grooming and hygiene, his speech had normal rhythm, rate, and tone, his thought processes were circumstantial, his affect and mood were appropriate, and he denied suicidal ideation, homicidal ideation, and hallucinations. PTSD and depressive disorder were diagnosed. A GAF score of 55 was assigned. In a July 2010 statement, the Veteran's wife reported that since their marriage in 1989, he has had episodes of anger and has been hypervigilant and excessively safety conscious because he always checked the doors and blinds. On November 2010 VA PTSD examination, it was noted that the Veteran had been married for 21 years, his relationship was stable, and he was prescribed Sertraline and Prazosin. He related that he had good relationships with his three children, played cards, attended church, and read books. The Veteran reported that he got up each morning, checked the windows and the doors, and sat with a hatchet in his hand while he watched TV because he always thought someone was trying to break into his house. On mental health examination, he was fully oriented, casually groomed, and fidgety, and had no psychomotor retardation. His speech was clear but stilted and rambling, with self-referential ideation. The Veteran's attitude was negative, mistrustful, and highly impulsive, and his affect ranged from mild flatness to mild lability. He denied hallucinations or illusions and had no difficulty with his memory. The examiner noted that the Veteran's potential for self-injury, suicide risk, and assault was absent, and indicated that he was employed for a number of years, had routine responsibility of self-care, played a good role in family functioning, had social relationships, and had leisure pursuits. However, it was noted that the Veteran had difficulty in successfully having more than superficial relationships. The examiner opined that hypervigilance was related to paranoid personality disorder and not PTSD, and that the Veteran did not currently meet the DSM-IV criteria for PTSD. Marijuana dependence, intermittent explosive disorder, and paranoid personality disorder were diagnosed, and the examiner indicated that they were all unrelated to the Veteran's military service. A GAF score of 70 was assigned. An April 2011 VA treatment record notes that the Veteran was well dressed and groomed, his speech was slightly pressured, but coherent and linear, his mood was euthymic, and his affect was consistent with his mood. He reported no suicidal or homicidal ideation. A GAF score of 45 was assigned. A June 2011 VA suicide risk assessment notes that the Veteran reported suicidal ideation 2-3 times a week in the last 30 days and that although he had made a plan to die by carbon monoxide inhalation in his garage with the car running, he had no current intent. He related that he felt stressed but had love for his family and a strong therapeutic relationship. The provider indicated that the estimated risk level was moderate, and that under the right conditions, the Veteran could survive as an outpatient. A safety plan was developed with the Veteran. A July 2011 VA treatment record notes that the Veteran reported anxiety and fear of unpredictable circumstances, and that he experienced some suicidal ideation after he was asked to return to VA for a second time to be examined because the examiner was not prepared on his first visit. He related that he felt somewhat hopeless about the situation but was able to distract himself, and has not had any suicidal thoughts since then. A GAF score of 45 was assigned. On July 2011 VA PTSD examination, the Veteran reported that he had good relationships with his wife and children, had a few friends who are Veterans to whom he was close, and he stayed in the basement in his "private space" frequently. He related that each day he watched TV in the morning, made coffee, rode his bike to get the newspaper, and worked in the yard. The Veteran reported that he did not drive, but could if necessary, had experienced no recent suicide attempts, but had suicidal ideation recently because he felt his health providers were not listening to him, and he took Sertraline for his symptoms. He related that he worked over 41 years at the post office, got along fairly well with most of his coworkers, and had some disputes, but described that as typical in the work environment. He denied any absences related to psychiatric symptoms, but said his supervisor made him angry on his last day because she would not let him walk around with his family. On mental health examination, the Veteran was dressed appropriately, he used a cane to ambulate, his motor behavior was unremarkable, his affect and mood were good, and his speech had normal rate and rhythm. His thought process was goal-directed and sequential, his memory was intact, and the examiner noted that there was no evidence of overt psychosis, but evidence of paranoia. The Veteran reported that he has trouble falling asleep because he was worried that someone would break into his house, he puts his chair in the corner of the basement and feels safe there, he checks windows and doors if he hears any noise, and his hypervigilant behavior started after he retired from the post office. He related that he was impatient and easily irritated, had not had current dreams or nightmares about PTSD stressors, and he had not had recent homicidal ideation or panic attacks. The examiner indicated that the Veteran's mental health testing results indicated that he had a depressed mood, a pessimistic outlook on life, hostility, blunted affect, anxiety, tension, and fearful apprehension, and that impulse control and frustration appeared to be a problem for him. It was noted that the Veteran was easily angered and hurt over trivial matters and that he acknowledged peculiar thoughts, persecutory ideas, and strange sensory experiences. The examiner noted that given the inconsistencies between his test responses, his treatment notes, and presentation during clinical interviews, it was difficult to determine whether or not there was a psychosis, but there was some evidence of paranoid ideation on test items and in clinical interview. The diagnostic impressions were generalized anxiety disorder, intermittent explosive disorder, alcohol induced anxiety disorder, and alcohol abuse. The examiner indicated that the Veteran met the criteria for intermittent explosive disorder because he had a history of poor affective regulation, gets angry over trivial matters, feels easily slighted, and has a history of behavioral dyscontrol. She indicated that the Veteran had mild to moderate impairment in social functioning related to this disorder, that irritability and temper caused mild impairment in his marriage and contributed to isolation from others, and that intermittent explosive disorder was not related to trauma exposure or military service. The examiner also noted that based on the totality of the information, the Veteran did not meet the criteria for PTSD because although treatment notes diagnosed PTSD, most notes do not describe any specific PTSD symptoms. A GAF score of 52 was assigned. On an additional July 2011 psychiatric evaluation provided in conjunction with the July 2011 VA PTSD examination, it was noted that the Veteran was referred to the provider to aid in the clarification of differential diagnoses. He reported that he attended monthly therapy sessions at VA for anxiety and took medication for the disorder. On testing, the Veteran acknowledged many symptomatic manifestations of PTSD with high frequency and intensity which included emotional numbing, survivor guilt, startle response, and sleep problems. He also reported distressing and intrusive recollection of military experiences, guilt over conduct, social isolation, a low threshold for frustration tolerance, poor impulse control, substance abuse, and cognitive difficulties. Regarding the Veteran's responses to the personality inventory, the provider questioned the validity of the profile due to the way some of the questions were answered. However, he indicated that if the Veteran endorsed the items accurately, his psychopathology should be very extensive, acute, and bordering on psychosis, or a severe personality disorder that was not readily apparent. The Veteran also related that he experienced hostility, depressed mood, blunted affect, and irritability and that he was experiencing a moderate to severe level of emotional distress characterized by dysphoric mood, brooding, and a pessimistic outlook on life. He reported suicidal ideation and past suicidal intent. The provider noticed anger and volatile impulses, that the Veteran's impulse control appeared to be problematic, probably due to a history of acting out in an aggressive manner, that he had a low threshold for frustration tolerance, and that his feelings were easily hurt. The awareness that his behavior was frightening to others also engendered guilt in the Veteran. The provider suggested that the Veteran might find some measure of comfort in a socially more distant and introverted existence or by limiting his relationships to a few selected people. Regarding cognitive functioning, he reported problems with attention, concentration, and memory, and that he experienced peculiar thoughts, persecutory ideas, and unusual sensory experiences bordering on psychosis or indicative of a long-standing psychological disorder. The provider indicated that close scrutiny to some of the critical items was highly recommended to ensure greater diagnostic clarity. An October 2011 VA treatment record notes that the Veteran discussed several of his traumatic experiences in Vietnam and his current symptoms. He completed a PCL-M that noted each of his PTSD symptoms and their severity. The Veteran related that repeated disturbing memories were extremely stressful, disturbing dreams of events in service were quite stressful, and that feeling very upset when reminded of a stressor, having physical reactions to a stressful memory, and avoiding thinking about the stressful experience, had a moderate impact. He related that he very often felt that he had lost interest in activities that he used to enjoy and felt distant from other people. Being watchful or on guard and being easily startled had an extreme impact on his functioning. He indicated that these problems made it very difficult for him to do his work, take care of things at home, and get along with other people. The provider indicated that she believed that his answers to the assessment were an accurate reflection of his current symptoms. In a January 2012 VA medical provider statement, PTSD was diagnosed secondary to the Veteran's fear of hostile military activity and from witnessing deaths of his fellow soldiers while serving in Vietnam. She explained that the PTSD was manifested in dreams, intrusive memories, and recollections of the events he experienced in Vietnam, causing disruption of sleep and daytime fatigue. The provider noted that the Veteran became upset emotionally when reminded of his stressful experiences and had been tearful and distressed when discussing them during their therapy sessions. He related that he avoided stimuli that might remind him of those experiences, and that he has attended a Vet Center PTSD group since 2007 which has allowed him to connect with other Veterans. The Veteran described symptoms of hypervigilance, anxiety, and emotional numbing, and that he "snaps" with minor provocation. He related that he had difficulty trusting others and feeling safe, had feelings of depression, had a lack of interest in activities that he used to enjoy, and experienced transient suicidal ideation, although he denied any current plan or intent. A GAF score of 45 was assigned. The provider opined that the Veteran's PTSD symptoms were at least as likely as not a result of his experiences in Vietnam. In a January 2012 VA medical statement, the Veteran's attending psychiatrist agreed with the January 2012 VA medical provider statement regarding his PTSD and opined that he had significant PTSD symptoms despite treatment (stemming from his service in Vietnam). A GAF score of 45 was assigned. From February to May 2012 the Veteran attended 12 VA group therapy sessions and successfully participated. An April 2012 VA treatment record notes diagnoses of PTSD with anger and insomnia. The Veteran reported nightmares that occurred 2-3 times a week and fewer panic attacks. A GAF score of 45 was assigned. A May 2012 VA treatment record notes that the Veteran became tearful when he discussed his feeling of helplessness at not being able to save soldiers because he was only used as a medic to deal with those who had already died. His current feelings of helplessness and desire for help were discussed. On September 2012 VA suicide risk assessment, the Veteran reported passing thoughts about death when he became frustrated with VA claim issues but denied plan or intent. He related that he had strong family ties and a strong therapeutic relationship. An October 2012 VA treatment record notes that the Veteran discussed a traumatic event in Vietnam. On mental status examination, his speech was normal, his mood was reflective, and his affect was consistent with his mood. He reported no suicidal or homicidal ideation, and a GAF score of 45 was assigned. An April 2013 VA treatment record notes that the Veteran's nightmares were less frequent and that he slept 3-4 hours a night. He denied dangerous ideation, his prescription for Zoloft was renewed, and a GAF score of 45 was assigned. On May 2013 VA psychiatric examination, the Veteran reported persistent recollections of trauma events during service, to include distressing dreams about Vietnam that occurred 2-3 nights per week. He described pseudo-dissociative episodes and avoidant behavior such as avoiding communicating with other Veterans about Vietnam and getting too close to people. The examiner opined that the Veteran's PTSD disability picture was best characterized as occupational and social impairment with reduced reliability and productivity. On mental status examination, the Veteran was oriented in all spheres, was cooperative but easily distracted, was dressed well, and had good hygiene. His mood was anxious, his affect was dramatic, and he denied auditory and visual hallucinations. His thought process was tangential, his speech had appropriate rate and tone, and his judgment and insight were fair. He reported symptoms of depressed mood, anxiety, hypervigilance, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty concentrating. A GAF score of 50 was assigned. In an August 2014 VA mental health statement, a VA provider (who also wrote the January 2012 VA provider statement) was asked to complete a questionnaire regarding the severity of the Veteran's PTSD from August 20, 2009 to present. The Board notes that this provider had been providing mental health counseling to the Veteran since at least 2011. The provider noted diagnoses of PTSD and depressive disorder, that the Veteran's current GAF score was 46, and that the highest GAF score during the period in question was 50. She indicated that the Veteran had received treatment for PTSD, but his symptoms had not remitted, and his prognosis was poor for full recovery. The provider noted positive clinical findings of deficiencies in family relations, persistent irrational fears, deficiencies in work or school, depression affecting the ability to function independently, appropriately, and effectively, intermittent inability to perform activities of daily living, deficiencies in mood, difficulty in adapting to stressful circumstances, and intrusive recollections of a traumatic experience. She opined that the Veteran would not be limited in his ability to perform activities within a schedule, would be mildly limited in his ability to remember locations and to sustain ordinary routine without supervision, would be moderately limited in his ability to maintain attention and concentration for extended periods, and would be markedly limited in his ability to work in coordination with or proximity to others without being distracted by them. The provider also noted that the Veteran was significantly impaired by symptoms of PTSD and that he reported symptoms of chronic sleep disturbance, nightmares, mistrust, depression, hypervigilance, and avoidance of trauma-related triggers. Considering the CAVC Memorandum decision (the law of the case) discussion regarding the significance of symptoms reported at various times, the Board finds that throughout from (the earlier effective date of) August 20, 2009, the Veteran's PTSD most closely approximated a disability picture consistent with occupational and social impairment with deficiencies in most areas as contemplated by the criteria for a 70 percent rating. Regarding severity prior to May 21, 2013, VA and private treatment records note reports of suicidal ideation and obsessional rituals. A February 2010 VA treatment record notes that he reported suicidal ideation, hypervigilance, anger outbursts, and that he tended to isolate. Although no records of VA or private mental health treatment were able to be obtained or were provided by the Veteran regarding treatment prior to February 2010, it was noted that he had been attending group therapy at a Vet Center during the past year. In a July 2010 statement, his wife reported that since their marriage in 1989, she had witnessed episodes of anger, and that he had been hypervigilant and excessively safety conscious because he always checked the doors and blinds, and a July 2010 VA treatment notes that he reported that he watches TV with a handgun at his side. On November 2010 VA examination, he reported that he got up each morning, checked the windows and the doors, and sat with a hatchet in his hand while he watched TV because he always thought someone was trying to break into his house. A June 2011 VA suicide risk assessment notes that the Veteran reported suicidal ideation 2-3 times a week in the last 30 days and that although he had made a plan to die by carbon monoxide inhalation in his garage with the car running, he had no current intent, and on July 2011 PTSD examination, he continued to report suicidal ideation and that his hypervigilant behavior started after he retired from the post office. It was noted that the Veteran was easily angered and hurt over trivial matters and that he acknowledged peculiar thoughts, persecutory ideas, and strange sensory experiences. January 2012 and September 2012 VA treatment records note the Veteran's ongoing reports of hypervigilance and suicidal ideation. In an August 2014 VA mental health statement, a VA provider who had been providing mental health treatment to the Veteran, completed a questionnaire regarding the severity of the Veteran's PTSD from August 20, 2009 to present. The provider noted clinical findings of deficiencies in family relations, persistent irrational fears, deficiencies in work or school, depression affecting the ability to function independently, appropriately, and effectively, intermittent inability to perform activities of daily living, deficiencies in mood, difficulty in adapting to stressful circumstances, and intrusive recollections of a traumatic experience throughout the period on appeal. The provider also noted that the Veteran was significantly impaired by symptoms of PTSD. The Board notes that the level of the Veteran's reported functioning during the period on appeal has fluctuated, and VA examiners prior to 2012 did not agree that his psychiatric symptoms were attributable to PTSD or related to his service. However, during the period on appeal, he reported hypervigilance and obsessional rituals (watching TV with a handgun nearby and sitting in his chair with a hatchet) and his wife related that she had witnessed his hypervigilance and excessive need to be safe for several years, suggesting that such rituals may have been present throughout the period on appeal. Additionally, he reported ongoing suicidal ideation since at least February 2010, and as noted above, in August 2014, a VA provider noted that throughout the period on appeal, the Veteran was significantly impaired by symptoms of PTSD. Therefore, what is presented by the findings in the VA and private treatment records is a PTSD disability picture at least approximating occupational and social impairment with deficiencies in most areas (see 38 C.F.R. § 4.7), and resolving remaining reasonable doubt regarding degree of disability in the Veteran's favor as required (see 38 C.F.R. § 4.3), the Board concludes that a 70 percent rating is warranted throughout from August 20, 2009 (the date of claim). The analysis progresses to whether a 100 percent schedular rating is warranted for any period of time under consideration. A psychiatric disability picture of less that total impairment is strongly suggested by the level of functioning related to employment and social relations. Throughout, prior to May 21, 2013, the Veteran had a stable marriage and had a few Veteran friends. In an August 2014 medical statement (discussing the period prior to May 21, 2013), the provider noted that the Veteran had intermittent inability to perform activities of daily living. Although this is a symptom included in the criteria for a 100 percent rating, it was noted on examinations and in private and VA treatment records that he maintained good hygiene and was able to perform activities of daily living (evidence of actual functioning at such times). Significantly, symptoms noted during the evaluation period also do not suggest total impairment. Gross impairment in thought process or persistent delusions and hallucinations were not clinically noted. Nor has he displayed grossly inappropriate behavior, inability to tend to minimal hygiene, or substantial memory loss. While he reported a long history of suicidal ideation, such ideation does not appear to have resulted in him being considered a persistent danger to himself or others. A PTSD disability picture of total occupational and social impairment is not shown prior to May 21, 2013, and a schedular 100 percent rating prior to that date is not warranted. 2., 3. Entitlement to ratings in excess of 10 percent for right and left knee disabilities (under Code 5010) prior to March 30, 2015 is denied; from that date, a 20 percent combined (10 percent under Code 5010 and 10 percent under Code 5257) rating, each, is granted for the right and left knee disabilities. The Veteran's treatment records show that he has manifested bilateral knee symptoms including pain and limitation of motion throughout the evaluation period. The Veteran's right and left knee disabilities have been rated 10 percent under Codes 5010 for painful, limited motion with objective evidence of arthritis. When evaluating a service-connected disability based on limitation of motion, the Board must take into consideration functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In DeLuca, the Court held that a diagnostic code based on limitation of motion does not subsume 38 C.F.R. §§ 4.40 and 4.45 and that the rule against pyramiding set forth in 38 C.F.R. § 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use, including use during flare-ups. Id. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by visible behavior of the veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Nonetheless, a rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Under Code 5003, degenerative arthritis established by X-ray findings is rated based on limitation of motion under the appropriate Code for the specific joint involved. When the limitation of motion of a specific joint involved is noncompensable under the appropriate Code, a 10 percent rating is warranted for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Code 5003. As a 10 percent rating is already assigned for each knee, consideration of Code 5003 would bring no further benefit to the Veteran. Therefore, Code 5003 will not be discussed further. The criteria for rating knee disabilities are found in Codes 5256 to 5263. Code 5256 provides for ratings from 30 to 60 percent for ankylosis of a knee. Under Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. Code 5258 provides for a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking", pain, and effusion into the joint. Under Code 5259, a 10 percent rating is warranted for cartilage, semilunar, removal of, symptomatic. Under Code 5260, limitation of knee flexion to 60 degrees or more warrants a 0 percent rating, to 45 degrees warrants a 10 percent rating, to 30 degrees warrants a 20 percent rating, and to 15 degrees warrants a 30 percent rating. Under Code 5261, limitation of knee extension at 5 degrees warrants a 0 percent rating, at 10 degrees warrants a 10 percent rating, at 15 degrees warrants a 20 percent rating, at 20 degrees warrants a 30 percent rating, at 30 degrees warrants a 40 percent rating, and at 45 degrees warrants a 50 percent rating. Code 5262 provides for ratings for impairment due to malunion or nonunion of the tibia and fibula. Code 5263 provides for a 10 percent rating for acquired (traumatic) genu recurvatum. 38 C.F.R. § 4.71a. [Codes 5256, 5259, 5262, and 5263 have no applicability in this matter, as the pathology or manifestations in the rating criteria under those Codes (ankylosis, cartilage, semilunar, removal of, symptomatic, malunion or nonunion of tibia or fibula, or genu recurvatum) are not shown. 38 C.F.R. § 4.71a.] A December 2009 left knee X-ray showed osteoarthritis, no fracture or bone destruction, and joint spaces were preserved. A right knee X-ray showed osteoarthritis, a 1.1 cm sclerotic area in the distal medial femur (probably a benign bone island), and no fracture was seen. The Veteran reported bilateral knee pain, and on examination there was neutral alignment, no effusion, no erythema, no edema, and no ecchymosis, bilaterally. There was mild tenderness to palpation in the medial and lateral compartments and full active range of motion (ROM), bilaterally. There was no apprehension or instability of the patella with flexion, anterior and posterior drawer testing was negative, and Lachman's was negative, bilaterally. Bilateral knee degenerative joint disease was diagnosed. Mobic was prescribed, and the Veteran was instructed to use capsaicin cream. A November 2010 private treatment record notes that the Veteran uses a cane as needed. On November 2010 VA PTSD examination, the Veteran reported the use of a right knee brace. On April 2011 VA joint examination, the Veteran reported grinding in both knees, decreased bilateral knee ROM, and that he occasionally had pain in his knees when he squatted. He related that he experienced some buckling in his knees, but no locking, he had been using a cane as needed for 20 years, mainly during cold weather, and he was able to walk 2 blocks. The Veteran reported that for the last 3-4 years he has used a stationary bike at home 30 minutes a day. Bilateral knee strain was diagnosed. On examination, the examiner noted that the Veteran had a cane, but used it minimally, and that his gait was normal. Bilateral knee ROM testing showed flexion to 130 degrees, and extension to 0 without painful limitation. There was no joint effusion, and McMurray's and Lachman's testing were negative, bilaterally. There was a slight amount of patellofemoral crepitus, bilaterally, and the Veteran was able to walk on his heels and toes without difficulty. Bilateral knee ROM was the same during active, passive, and repetitive motion, and there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or flare-up. The examiner indicated that the record showed no incapacitating episodes, and the current examination showed no radiation of pain and no neurological findings that would affect the Veteran's usual occupation or daily activities. On May 2013 VA knee examination, bilateral knee strain and bilateral knee arthritis were diagnosed. The Veteran reported bilateral knee pain, flare-ups, that he took medication for his knee pain, and regular use of a cane. Right knee ROM testing showed right and left knee flexion to 130 degrees, with pain at 130 degrees and extension to 0 degrees, with no pain. The Veteran was able to perform repetitive use testing, with no additional limitation in ROM or functional loss after repetitive use testing, bilaterally. No pain was shown on palpation of either knee joint. Muscle strength testing was normal, bilaterally. Joint stability testing normal in each knee, and there was no evidence or history of recurrent patellar subluxation or dislocation, bilaterally. No current meniscal disorder was shown in either knee. The examiner opined that the Veteran's bilateral knee disability had no functional impact. An October 2013 VA treatment record notes that the Veteran reported that his legs lock up or buckle if he tries to bend his knees while walking. On examination, ROM testing showed normal flexion and extension and a negative drawer sign, bilaterally. No edema was shown, and the Veteran reported use of a cane for ambulation. An August 2014 VA treatment record notes that the Veteran reported bilateral knee pain, that he could walk straight with no difficulty, and that his knee joints click and lock or catch, when he tries to extend after bending. A September 2014 left knee MRI showed that the left ACL and PCL were grossly intact, and mucinous degenerative changes to the posterior horn of the medial meniscus were shown. No gross tear was found, and mild sprains were shown in the medial collateral ligament and lateral collateral ligament. Degenerative changes were noted in the patella, the extensor retinaculum appeared grossly intact, and edematous changes in the patella soft tissues, along the attachment of the medial patellofemoral retinaculum and the vastus medialis tendon sheath, and along the myofascial sheath and the deep fascial anatomy were shown. An approximate 9-mm sized old osteochondral defect was seen along the medial condyle as well as lateral condyle, and degenerative changes were noted along the proximal tibia. In the right knee there was a nondisplaced tear in the posterior horn of the right medial meniscus, and mild sprains of the ACL, medial collateral ligament, and lateral collateral ligament, were shown. The extensor mechanism appeared grossly intact, and degenerative changes in the knee joint and patella were shown. Large spurs were noted along the superior patella. Edematous changes were shown in the patella soft tissues and along the attachment of the medial patellofemoral retinaculum. A November 2014 VA treatment record notes that the Veteran reported bilateral knee pain, occasional bilateral swelling, occasional left knee crepitus and locking, and occasional right knee buckling. He related that he used a cane for ambulation and that he had trouble traversing stairs. ROM showed flexion to 125 degrees and extension to 0 degrees, bilaterally, and both knees were stable to varus and valgus stress. A left knee MRI showed degenerative changes to the posterior horn medial meniscus, and a right knee MRI showed a nondisplaced tear of the posterior horn of the medial meniscus. A December 2014 VA treatment record notes that the Veteran reported bilateral knee pain that was aggravated by weather change, squatting, bending, lifting weights, and walking 1 mile. A March 2015 VA treatment record notes that the Veteran reported constant anterior bilateral knee pain that worsened with flexion and that he had difficulty bending his knees. He related that his knees often give out and lock up on him, and he wore bilateral knee sleeves and used a cane. On examination, the bilateral knees were not tender to palpation, there was no effusion, and ROM testing showed flexion to 100 degrees and extension to 0 degrees, bilaterally. The Veteran had normal quad and hamstring strength and no varus, valgus, or anterior-posterior (AP) instability. A right knee X-ray showed moderate degenerative changes and possible healed osteochondral changes in the medial condyle, some slight effusion, severe degenerative changes in the patella with spurs superiorly noted, soft tissue swelling, and osteopenic changes. A left knee X-ray showed mild degenerative joint disease, moderate degenerative changes in the patella, a small healed osteochondral defect in the medial condyle, slight effusion, no gross fractures, and some osteopenic changes. On March 2015 VA knee examination, bilateral knee strain, and bilateral knee arthritis were diagnosed. The Veteran reported flare-ups that manifested as occasional pain and that he experienced no functional loss with repeated use of his knees over time. Right and left knee ROM testing showed flexion to 120 degrees with pain that did not result in functional loss and extension to 0 degrees with no pain. No pain was reported with weight-bearing or pain on palpation of either knee joint. Crepitus was shown bilaterally. The Veteran was able to perform repetitive use testing, bilaterally, with no additional functional loss or loss of ROM. The examiner indicated that the Veteran was not being examined after repetitive use over time or during a flare-up, and that the examination was neither medically consistent or inconsistent with his statements describing functional loss with repetitive use over time or during a flare-up. Muscle strength testing was normal bilaterally, and no muscle atrophy or ankylosis was shown. Joint stability testing was normal, and there was no history of recurrent effusion. No current meniscal disorder was found in either knee. The examiner also noted that there was no recurrent subluxation, lateral instability, semilunar cartilage condition, impairment of tibia or fibula, or genu recurvatum in either knee. It was noted that the Veteran reported regular use of a brace and cane, but the disorder for which the brace and cane were used was not indicated. The examiner opined that the Veteran's bilateral knee disability had no functional impact because there was no additional pain, weakness, fatigability, or incoordination that would significantly limit functional ability during flare-ups, or when the joint was used repeatedly over a period of time. A June 2015 VA treatment record notes that the Veteran reported constant anterior knee pain that worsened with flexion and traversing stairs. He related that he had recently completed physical therapy, that his knees still gave out on him when he climbed stairs, and that he wore bilateral knee braces and used a cane. On examination, the knees were not tender to palpation, and trace effusion was shown, bilaterally. Right and left knee ROM testing showed flexion to 110 degrees, extension to 0 degrees, muscle strength testing showed normal quad and hamstring strength, bilaterally, and stability testing showed no varus, valgus, or AP instability, bilaterally. An October 2015 VA treatment record notes that the Veteran reported constant bilateral anterior knee pain that worsened with walking and weight-bearing. He related that his knees gave out, locked up, and cracked, and that he wore bilateral knee braces and used a cane. On examination, there was no effusion or tenderness to palpation in either knee and right and left knee ROM testing showed flexion to 110, extension to 0, and no varus, valgus, or AP instability. A September 2015 right knee MRI showed patellofemoral DJD and medial joint DJD, and a left knee MRI showed patellofemoral DJD, medial and lateral joint DJD, and a small radial tear of the medial meniscus. September 2016 bilateral knee X-rays showed (in comparison with July 2014 X-rays) very little significant interval change with degenerative mild joint space narrowing of the medial compartment and patellofemoral joint spaces. On February 2017 VA back examination, the Veteran reported regular use of a cane to assist with ambulation and balance due to his knee disability. A March 2017 VA treatment record notes that the Veteran reported that he used a cane to assist with ambulation and that his bilateral knee pain was 8/10. At the October 2017 Travel Board hearing, the Veteran testified that he had increased instability in his knees. A May 2018 VA treatment record notes that the Veteran reported bilateral knee pain, that his left knee occasionally locked, and that he felt like he periodically loses his balance due to his left knee giving out. He related that he had difficulty squatting, navigating stairs, and dancing with his wife. Right and left knee ROM testing showed that both knees were within normal limits. Laxity and hyperextension were noted in both knees. The provider indicated that laxity was shown in the lower extremity ligaments with hyperextension of the knees, that there was laxity of the right ACL with anterior translation of tibia on femur, that left MCL laxity was seen with valgus testing, and that very hypermobile patellas and weakness in the quads in both knees was leading to increased patellofemoral compression during functional movement. Chronic pain was shown that inhibited motor control to lower extremity musculature. An October 2018 VA treatment record notes that the Veteran reported that he felt like his knees were locking up on him and that he used a cane and knee braces. On examination, there was mild bilateral effusion and crepitus, and anterior drawer testing was negative. ROM testing was good bilaterally. A November 2018 right knee MRI showed trace joint effusion and that there appeared to be a 2 x 1.4 x 0.8 cm intra-articular body lying posterior to the lateral femoral condyle. The menisci, anterior and posterior cruciate ligaments, and medial collateral and lateral collateral ligamentous complex were intact. There was no evidence of muscle atrophy or edema. Grade 3 medial compartment chondromalacia was present with subchondral cystic change at the femoral condyles along with grade 2 lateral and patellofemoral chondromalacia. A left knee MRI showed a very small radial tear of the posterior horn of the medial meniscus and that the remaining ligaments, tendons, and lateral meniscus were intact. Tricompartmental chondromalacia was also shown. On January 2019 VA knee examination, bilateral knee strain and bilateral knee degenerative arthritis were diagnosed. The Veteran reported catching and weakness in both knees and no flare-ups, but he indicated that he experienced functional loss because he cannot bend, squat, or carry heavy weights. Right and left knee ROM testing showed flexion to 140 and extension to 0 with no pain. There was no pain with weight-bearing and no tenderness to palpation of the knee joint, bilaterally. There was crepitus in each knee. The Veteran was able to perform repetitive use testing with no additional functional loss or loss of ROM, bilaterally. The examiner indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time, and muscle strength testing was normal. No muscle atrophy was shown in either knee, and joint stability testing was normal, bilaterally. McMurray's testing was negative, bilaterally. The examiner indicated that a right knee meniscus condition was shown but there were no current symptoms. The Veteran reported the use of a cane and bilateral soft knee braces. The examiner noted that he had developed mild generalized arthritis of both knees and that multiple examinations have not provided an explanation for his symptoms of locking and weakness. The findings on current examination are very slight with good motor, good motion, and no localized tenderness. The evidence of record, outlined above, shows that throughout the Veteran's right and left knee disabilities have been manifested by limitation of motion with flexion limited to 100 degrees at worst. Extension was consistently to 0 degrees (i.e., full) bilaterally. Accordingly, neither flexion nor extension has been limited to a compensable degree (as a 10 percent rating requires flexion limited to 45 degrees or extension limited at 10 degrees). The maximum limitation noted is with consideration of all factors to include pain and flare-ups based on the Veteran's reports; therefore, an increase based on factors such as painful motion, use, or weight-bearing is not warranted. The current 10 percent rating has been assigned based on painful, limited motion. Accordingly, an increase in the rating under Codes 5260 and/or 5261 is not warranted for either knee. The Board has considered the applicability of Code 5258 for the Veteran's left and right knees. On May 2013 VA knee examination, no current meniscal disorder was shown in either knee. A September 2014 right knee MRI showed a nondisplaced tear in the posterior horn of the right medial meniscus. A November 2014 VA treatment record notes the Veteran's report of occasional left knee crepitus and locking. An October 2015 VA treatment record notes that the Veteran reported that his knees periodically locked up, and a left knee MRI showed a small radial tear of the medial meniscus. A November 2018 right knee MRI showed trace joint effusion and that the menisci, anterior and posterior cruciate ligaments, and medial collateral and lateral collateral ligamentous complex were intact. There was no evidence of muscle atrophy or edema. A left knee MRI showed a very small radial tear of the posterior horn of the medial meniscus and that the remaining ligaments, tendons, and lateral meniscus were intact. On January 2019 VA examination, the examiner indicated that a right knee meniscus condition was shown, but there were no current symptoms. Based on the competent evidence of record, there is no indication that during the period on appeal, that either knee had dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Right and left knee MRIs did show slight meniscus tears in both knees, and there were periodic reports of locking, pain, and at least slight swelling in the knee; however, no VA or private provider indicated that right or left knee semilunar cartilage was dislocated, which would warrant a rating under Code 5258. Accordingly, a separate rating for a left or right knee disability under Code 5258 is not warranted at any time during the period on appeal. The Veteran also asserts that separate ratings for instability are warranted for his knee disabilities. On November 2010 VA PTSD examination, the Veteran reported the use of a right knee brace, but no further information was provided regarding duration of use or the reason for use. On April 2011 VA joint examination, he related that he experienced some buckling in his knees, but no locking, he had been using a cane as needed for 20 years, mainly during cold weather, and he was able to walk 2 blocks. On examination, the examiner noted that the Veteran had a cane, but used it minimally, and that his gait was normal. An October 2013 VA treatment record notes that the Veteran reported that his legs lock up or buckle if he tries to bend his knees while walking; however, an August 2014 VA treatment record notes that the Veteran reported bilateral knee pain and that he could walk straight with no difficulty. A November 2014 VA treatment record notes that the Veteran reported bilateral knee pain, occasional bilateral swelling, occasional left knee crepitus and locking, and occasional right knee buckling. A March 30, 2015 VA treatment record notes that the Veteran reported constant anterior bilateral knee pain that worsened with flexion and that he had difficulty bending his knees. He related that his knees often gave out and locked up on him, and that he wore bilateral knee sleeves, and used a cane. On March 2015 VA knee examination, the Veteran reported regular use of a brace and cane. A June 2015 VA treatment record notes that he related that he had recently completed physical therapy, that his knees still gave out on him when he climbed stairs, and that he wore bilateral knee braces and used a cane. An October 2015 VA treatment record notes that the Veteran related that his knees gave out, locked up, and cracked, and that he wore bilateral knee braces and used a cane. On February 2017 VA back examination, the Veteran reported regular use of a cane to assist with ambulation and balance due to his knee disability. A May 2018 VA treatment record notes that the Veteran reported that he felt like he periodically loses his balance due to his left knee giving out. The provider indicated that laxity was shown in the lower extremity ligaments with hyperextension of the knees, that there was laxity of the right ACL with anterior translation of tibia on femur and that left MCL laxity was seen with valgus testing. On January 2019 VA examination, the Veteran reported use of a cane and bilateral soft knee braces. VA examinations throughout have found no objective evidence of knee instability, and although the Board notes the Veteran's reports of periodic buckling and/or periodic use of a brace since November 2010, since March 2015, he has consistently reported that his knees gave out when walking or climbing stairs and that he used knee braces or sleeves and a cane. Considering the CAVC Memorandum decision admonition regarding "skewing" consideration of objection findings over lay statements, and resolving reasonable doubt in the matter in favor of the Veteran, as required (see 38 C.F.R. § 4.3) the Board finds the disability picture presented is one of at least perceived (if not actual found on testing) instability. As the examination reports show tests for stability were normal, the Board finds that more than slight right and left knee instability is shown ar any time from March 30, 2015 (the first report of consistent bilateral knee brace and cane use in conjunction with a report of both knees giving way during the period on appeal). Accordingly, the Board finds that separate 10 percent, but no higher, ratings for slight instability under Code 5257 are warranted for the right and left knees from March 30, 2015. 4. Entitlement to a TDIU rating is granted from the (earlier effective date) of October 1, 2009. A TDIU rating may be assigned, where the schedular rating is less than total, when the Veteran is unable to maintain a substantially gainful occupation as a result of service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and work experience, but not age or impairment due to nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran initially filed his claim seeking service connection for PTSD in August 2009, and an October 2013 rating decision granted service connection for PTSD, effective August 20, 2009. In May 2014, the Veteran formally filed a claim for TDIU based on his service-connected PTSD and knee disabilities. Once the issue of the appropriate initial rating for the Veteran's PTSD was appealed by virtue of a November 2009 informal Notice of Disagreement (NOD), entitlement to a TDIU rating became part and parcel of the underlying PTSD claim. Harper v. Wilkie, 30 Vet.App. 356, 359 (2018) (wherein the CAVC held that TDIU remains part and parcel of an increased evaluation claim unless the claimant already received the highest possible disability rating for the entire period on appeal). As noted above, a May 2015 rating decision granted TDIU effective May 21, 2013. A February 2010 private treatment record notes that the Veteran reported that he was always on edge, was depressed, and had thoughts of suicide, but had not attempted suicide. The Veteran related that he occasionally felt helpless, but not hopeless, and that although he enjoyed dancing (and found peace dancing), he experienced anger outbursts and tended to isolate. A July 2010 VA treatment record notes that the Veteran reported verbal outbursts in response to a perceived threat, that he sat alone in his basement if his wife was at treatment, that he becomes startled by the slightest noise, and that he watched TV with his handgun at his side. In a July 2010 statement, the Veteran's wife reported that since their marriage in 1989, he has had episodes of anger and that he has been hypervigilant and excessively safety conscious because he always checked the doors and blinds. On November 2010 PTSD examination, the Veteran reported that he got up each morning, checked the windows and the doors, and sat with a hatchet in his hand while he watched TV because he always thought someone was trying to break into his house. On July 2011 PTSD examination, the Veteran reported that he had experienced no recent suicide attempts, but had suicidal ideation recently because he felt his health providers were not listening to him. He related that his hypervigilant behavior started after he retired from the post office, he was impatient and easily irritated, he had not had current dreams or nightmares about PTSD stressors, and he had not had recent homicidal ideation or panic attacks. The examiner indicated that the Veteran's mental health testing results indicated that he had a depressed mood, a pessimistic outlook on life, hostility, blunted affect, anxiety, tension, and fearful apprehension, and that impulse control and frustration appeared to be a problem for him. It was noted that the Veteran was easily angered and hurt over trivial matters and that he acknowledged peculiar thoughts, persecutory ideas, and strange sensory experiences. A July 2011 psychiatric evaluation notes that the Veteran reported suicidal ideation and past suicidal intent. The provider noticed anger and volatile impulses, that his impulse control appeared to be problematic, probably due to a history of acting out in an aggressive manner, that he had a low threshold for frustration tolerance, and that his feelings were easily hurt. The awareness that his behavior was frightening to others also engendered guilt in the Veteran. The provider suggested that the Veteran might find some measure of comfort in a socially more distant and introverted existence or by limiting his relationships to a few selected people. An October 2011 VA treatment record notes that the Veteran completed an assessment and related in part, that he very often felt that he had lost interest in activities that he used to enjoy and felt distant from other people. He related that being watchful or on guard and being easily startled had an extreme impact on his ability to function. He indicated that these problems made it very difficult for him to do his work, take care of things at home, and get along with other people. The provider indicated that she believed that his answers to the assessment were an accurate reflection of his current symptoms. As noted above, in August 2014, a VA provider who was very familiar with the Veteran, was asked to opine regarding the severity of his PTSD from August 20, 2009 to the present. She indicated that the Veteran had received treatment for PTSD, but his symptoms had not remitted, and his prognosis was poor for full recovery. The provider noted positive clinical findings of deficiencies in family relations, persistent irrational fears, deficiencies in work or school, depression affecting the ability to function independently, appropriately, and effectively, intermittent inability to perform activities of daily living, deficiencies in mood, difficulty in adapting to stressful circumstances, and intrusive recollections of a traumatic experience. She opined that the Veteran would not be limited in his ability to perform activities within a schedule, would be mildly limited in his ability to remember locations and to sustain ordinary routine without supervision, would be moderately limited in his ability to maintain attention and concentration for extended periods, and would be markedly limited in his ability to work in coordination with or proximity to others without being distracted by them. The provider also noted that the Veteran was significantly impaired by symptoms of PTSD and that he reported symptoms of chronic sleep disturbance, nightmares, mistrust, depression, hypervigilance, and avoidance of trauma-related triggers. As this decision grants a 70 percent rating for PTSD from August 20, 2009, from that date, the Veteran's service-connected disabilities have included: PTSD (rated 70 percent), right and left knee disabilities (rated 10 percent, each, from April 16, 2010) and hemorrhoids (rated 0 percent); the combined rating is 70 percent from August 20, 2009 and 80 percent from April 16, 2010; the schedular rating requirement for a TDIU rating is met throughout from August 20, 2009. [The Board notes that the Veteran has other service-connected disabilities; however, the effective dates for such disabilities are after May 21, 2013.] The evidence of record reasonably shows that the Veteran's service-connected PTSD has been such that it precluded him from maintaining regular, substantially gainful employment from October 1, 2009 (the first day of the month following his retirement from the post office). His PTSD, as described, impacted adversely since then on his ability to maintain employment due to his tendency to isolate, anger outbursts, extreme obsessive rituals and a low threshold for frustration tolerance. The Veteran's VA medical providers have described the limiting effects of his PTSD on his ability to work. Although VA and private psychiatric treatment records for the period prior to February 2010 are unavailable and/or were not provided by the Veteran the lay statements by the Veteran and his wife (especially regarding hypervigilance and obsessional behavior for several years) and the medical statements and opinions by VA providers suggest that he suffered from such PTSD symptoms at least from October 1, 2009. Therefore, it is reasonably shown that since October 1, 2009 his service-connected PTSD has resulted in functional limitations incompatible with regular substantially gainful employment. Accordingly, a TDIU rating is warranted from October 1, 2009. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bayles, 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.