Citation Nr: 21068110 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-58 965 DATE: November 9, 2021 ORDER A rating in excess of 50 percent prior to June 20, 2018, and in excess of 70 percent thereafter for posttraumatic stress disorder (PTSD) is denied. A rating in excess of 10 percent for status post left wrist fracture, healed, with residual mild chronic tendonitis is denied. FINDINGS OF FACT 1. For the appeal period prior to June 20, 2018, the Veteran's PTSD was manifested by symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. As of June 20, 2018, the Veteran's PTSD is manifested by symptomatology resulting in occupational and social impairment with deficiencies in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment. 3. For the entire appeal period, the Veteran's status post left wrist fracture, healed, with residual mild chronic tendonitis is manifested by painful and limited motion, without ankylosis, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, and incoordination, or as a result of repetitive motion and/or flare-ups. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent prior to June 20, 2018, and in excess of 70 percent thereafter for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a rating in excess of 10 percent for status post left wrist fracture, healed, with residual mild chronic tendonitis have not been met. 38 U.S.C. §§ 1155, 5107 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5024-5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1992 to September 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2016 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In May 2021, the Board remanded the claims on appeal, as well as a claim for service connection for a bilateral knee disorder, for additional development. While on remand, a July 2021 rating decision granted service connection for bilateral knee strains. As such is a full grant of the benefits sought with respect to such issue, it is no longer before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Additionally, an August 2021 rating decision awarded a 70 percent rating for the Veteran's PTSD, effective June 20, 2018. However, as he is presumed to be seeking the maximum benefit for a disability and a higher rating for such disability remains available on appeal, such claim for a higher rating remains in appellate status. A.B. v. Brown, 6 Vet. App. 35, 38 (1993). The case now returns for further appellate review. As a final matter, the Board notes that, subsequent to the issuance of the August 2021 supplemental statement of the case, additional evidence, to include updated VA treatment records, was associated with the file. The Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such evidence; however, as it is either irrelevant to the issues on appeal or contain findings that are duplicative of those previously considered by the AOJ, the Board finds no prejudice to the Veteran in proceeding with a decision at this time. 38 C.F.R. § 20.1305(c). Increased Rating Claims Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. The appeal period before the Board stems from the Veteran's January 11, 2016, claims for increased ratings for his PTSD and left wrist disability, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). 1. Entitlement to a rating in excess of 50 percent prior to June 20, 2018, and in excess of 70 percent thereafter for PTSD. As relevant to the appeal period, the Veteran's PTSD is evaluated as 50 percent disabling prior to June 20, 2018, and as 70 percent disabling thereafter pursuant to the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. Under DC 9411, a 50 percent rating is warranted when 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; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted when 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is 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 United States Court of Appeals for the Federal Circuit has held that the evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 11718; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation 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). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the United States Court of Appeals for Veterans Claims (Court) held that the language of the General Rating Formula "indicates that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (August 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, 29 Vet. App. 221 (2018). The pertinent evidence of record related to the Veteran's claim for an increased rating for his PTSD consists of VA examination reports dated in February 2016, June 2018, October 2019, and July 2021; his testimony provided at his November 2020 Board hearing; and his private and VA treatment records dated throughout the appeal period, to include a May 2019 Mental Disorders Disability Benefits Questionnaire (DBQ). In this regard, at a February 2016 VA examination, the examiner diagnosed pervasive depressive disorder and PTSD, which were found to result in occupational and social impairment with reduced reliability and productivity, which is commensurate with a 50 percent rating under the General Rating Formula. Here, he found that it was possible to differentiate what symptom was attributable to each of the Veteran's diagnoses. Specifically, the examiner noted the Veteran's negative moods; sleep impairment; difficulty in adapting to stressful circumstances, including work or a work-like setting; near-continuous panic or depression; poor concentration; irritability; and hopelessness were due to his pervasive depressive disorder. He further noted that the Veteran's recurring dreams, intrusive memories, negative cognitive alterations and moods, hypervigilance, sleep impairment, and avoidance behaviors were due to his PTSD. In this regard, the examiner noted that the Veteran's PTSD was estimated to account for 25 percent of the identified level of functional impairment. The examiner further indicated that the Veteran's psychiatric disability resulted in additional symptoms of depressed mood; anxiety; suspiciousness; near-continuous panic or depression; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. Furthermore, the examiner stated that the Veteran was appropriately dressed and groomed; his thinking was linear and rational; and he denied any history of suicidal or homicidal ideation. He also noted that, while the Veteran had been unemployed since 2015, and, while he was in the process of divorcing, he had a positive relationship with both of his children. VA treatment records dated from March 2016 to November 2017 reflect ongoing mental health treatment. Specifically, mental status examinations revealed that the Veteran reported experiencing depressed mood and sleep impairment. It was also noted that he was oriented and had fair/good judgment, an intact memory, good insight, and linear thought process. It was also observed that the Veteran was well-groomed, and consistently denied hallucinations and homicidal ideation. Additionally, he indicated that he enjoyed spending times with his kids and aspired to go back to school for an MBA. Here, the Veteran reported that he had received a bachelor's degree, last worked as a community resource advisor, and had various previous administrative assistance positions. A March 2016 VA treatment record reveals the Veteran's report of passive suicidal ideation with no intentions of harming himself or a specific plan. An additional March 2016 VA treatment record reflects that the Veteran told his spouse that he wanted a divorce, but he was devoid of suicidal ideation or intent, suggesting a sense of relief/escape. VA treatment records dated in June and July 2017 notes the Veteran's continued denial of suicidal/homicidal ideation. A September 2017 VA treatment record notes the Veteran's interest in employment; however, he had shown minimal follow-through. In June 2018, the Veteran was afforded an additional VA examination, at which time the examiner noted diagnoses of major depressive disorder and PTSD, which were found to result in occupational and social impairment with deficiencies in most areas, which is commensurate with a 70 percent rating under the General Rating Formula. Here, she found that it was possible to differentiate what symptom was attributable to each of the Veteran's diagnoses. Specifically, the examiner noted the Veteran's bad dreams and intrusive memories were secondary to his PTSD, and his remaining symptoms were secondary to both his major depression and PTSD. In this regard, the examiner noted that secondary impairment of social and occupational functioning due to the Veteran's major depressive disorder and PTSD overlapped and were interrelated; thus, it was not possible to differentiate what impairment was attributable to each diagnosis. The examiner further indicated that the Veteran's psychiatric disability resulted in additional symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Furthermore, the examiner stated that the Veteran was appropriately dressed and adequately groomed; his thinking was linear and logical. There was no indication of hallucinations or delusions, and the Veteran did not appear to pose a threat of danger or injury to self or others. The examiner also noted that the Veteran did not maintain relationships with his parents, stepmother, or siblings due to issues that occurred during his childhood. Additionally, he was in the process of divorcing his spouse, but they still lived together with their small children. He also maintained relationships with other veterans he met through treatment, but otherwise had a very limited social life. The examiner further observed that the Veteran had a bachelor's degree, but was not currently working as he had difficulty finding work. It was also noted that he last worked in 2015, but had multiple tardies and absences due to stress at home and emotional problems. VA treatment records dated from August 2018 to April 2019 reflect that the Veteran experienced depression, anxiety, and stress. It was noted that he had an intact memory, appropriate thought content, no hallucinations, good judgment, a neat/clean and appropriate appearance/hygiene, intact insight, and linear/clear thought process, and was oriented. He consistently denied suicidal/homicidal ideation. A November 2018 counseling record for VA's Veteran Readiness and Employment program reflects that the Veteran previously completed a bachelor's degree and, while he was not working, he reported that such was due to family issues as opposed to his service-connected disabilities. As pertinent to his PTSD, he reported that he lost his last job in 2015 due to anxiety and depression. He also indicated that he gets overwhelmed, lacks initiative and planning, has difficulty with reliability and punctuality, and did not perform well under pressure. Ultimately, the counselor found that the Veteran did not have an employment handicap as he has adequate training, experience, and transferable skills that qualify him for suitable employment. A December 2018 private treatment record notes the Veteran's report of fleeting thoughts of suicide; however, he denied current intent, plan, and means. A January 2019 VA treatment record reveals that the Veteran was scheduled to go to San Francisco in February for acting/theater, but, if that did not work out, he would focus on getting his business degree. In a May 2019 DBQ, Dr. V.M. noted diagnoses of major depression disorder and PTSD. Here, she indicated that the Veteran exhibited depression, lack of motivation, anger outbursts, difficulty with authority figures, interpersonal difficulties, intimacy and attachment difficulties, social isolation, memory and concentration issues, and suicidality. Dr. V.M. noted that the Veteran was involuntarily hospitalized for suicidal ideation in 2019. On VA examination in October 2019, the examiner noted a diagnosis of PTSD, which was found to result in occupational and social impairment with deficiencies in most areas, which is commensurate with a 70 percent rating under the General Rating Formula. In this regard, the examiner indicated that the Veteran's psychiatric disability results in symptoms of depressed mood; anxiety; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and neglect of personal appearance and hygiene. Additionally, she noted that the Veteran denied current suicidal/homicidal ideation, but endorsed a history of suicidal ideation without intent, plan, or means. He also denied hallucinations/delusions; he was dressed appropriately and his hygiene/grooming was appropriate; he was oriented; his remote/recall/abstract abilities were intact; and thought content was linear and coherent. The examiner further noted that, while the Veteran was going through a divorce, which he attributed to his PTSD symptoms, he was on good terms with his spouse for the sake of their children and he maintained a positive relationship with his children who he saw weekly. However, he denied close friendships or engagement with immediate family members. It was further noted that the Veteran was still unemployed, but had a bachelor's degree. He indicated that he had excessive tardiness, issues with management and co-workers, and had difficulty handling the workload. Finally, it was observed that he was involuntarily psychiatrically hospitalized in 2018 and he endorsed occasional statements from his spouse related to neglect of his personal appearance and hygiene. VA treatment records dated in March and April 2020 reveal the Veteran's denial of suicidal/homicidal ideation. A July 2020 VA treatment record notes the Veteran's report that he was looking forward to going to Patriots and Paws. At the Veteran's November 2020 Board hearing, he reported that his PTSD had increased in severity as he and his spouse separated for some time due to his depression, he had been involuntarily committed for psychiatric symptoms within the last 1-2 years, experienced suicidal ideation, went weeks without showering, and had difficulty controlling his anger and impulses, focusing, remembering things, communicating, and sleeping. On VA examination in July 2021, the examiner noted a diagnosis of PTSD, which was found to result in occupational and social impairment with deficiencies in most areas, which is commensurate with a 70 percent rating under the General Rating Formula. In this regard, the examiner indicated that the Veteran's psychiatric disability results in symptoms of depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss; flattened affect; speech intermittently illogical, obscure, or irrelevant; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and impaired impulse control. Additionally, he noted that the Veteran denied current suicidal/homicidal ideation and a history of hallucinations; and his hygiene was within normal limits. The examiner also noted that, while the Veteran had previously been separated, he and his spouse recently reconciled. However, he did not enjoy being at home and did not have any friends. It was further observed that the Veteran last worked in March 2017, but was terminated due to losing his temper, calling in sick, and difficulty getting along with others. In this regard, the examiner noted that the Veteran's PTSD moderately to significantly limited his ability to work. Based on the foregoing, the Board finds that, a rating in excess of 50 percent for PTSD, for the appeal period prior to June 20, 2018, is not warranted. In this regard, the Veteran has never reported symptoms commensurate with a 100 percent rating, nor do treatment records or examinations reflect any such symptoms throughout such appeal period. Furthermore, while he has reported some symptoms as contemplated by a 70 percent rating, such are not shown to be of a nature, frequency, duration, and severity as to result in social and occupational impairment with deficiencies in most areas. Here, while the Veteran had been found to have difficulty in adapting to stressful circumstances (including work or a work like setting) and near-continuous panic or depression, the February 2016 VA examiner explicitly determined that such symptomatology was not attributable to his PTSD. Furthermore, while the Veteran endorsed passive suicidal ideation in March 2016, he indicated that he had no intentions of harming himself or a specific plan; and he denied such ideation shortly thereafter. Notably, the Veteran predominantly denied suicidal ideation during this appeal period, to include at the February 2016 VA examination. Moreover, the remainder of the Veteran's psychiatric symptoms noted throughout this appeal period are explicitly contemplated by the rating criteria for a 10, 30, or 50 percent rating under the General Rating Formula. Furthermore, regardless of the classification of the Veteran's symptoms under the General Rating Formula, the Board finds that the totality of such, to include consideration of their nature, frequency, duration, and severity, result in, at most, occupational and social impairment with reduced reliability and productivity prior to June 20, 2018. In this regard, while the Veteran was separated and began divorce proceedings during such portion of the appeal period, he continued to have a relationship with his spouse in regard to their children, had a positive relationship with his children, and maintained a relationship with other veterans he met through treatment. Furthermore, while he was not working during the appeal period, which he attributed to PTSD-related symptoms during his VA examinations, his VA treatment records reflect his desire to obtain his MBA and his report that he lost his last job due to family issues unrelated to his PTSD. He was also attending UCLA Extension and taking one class. Moreover, in consideration of the totality of the Veteran's PTSD symptomatology, the February 2016 VA examiner, a psychologist who has the necessary expertise to evaluate psychiatric disabilities, determined that such resulted in, at most, in occupational and social impairment with reduced reliability and productivity, which is commensurate with a 50 percent rating under the General Rating Formula. Thus, the Board finds that, as the probative evidence of record does not show that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas or total occupational and social impairment for the appeal period prior to June 20, 2018, a rating in excess of 50 percent for such disability is not warranted. Similarly, the Board finds that, as of June 20, 2018, a rating in excess of 70 percent for PTSD is not warranted. Specifically, there is no evidence that the Veteran's PTSD results in symptomatology of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Furthermore, while an intermittent inability to perform activities of daily living was noted, the Board finds that the frequency, duration, and severity of such symptom does not result in total occupational and social impairment. In this regard, the Board finds that the occasional failure to engage in regular grooming while at home is not shown to be of a nature, frequency, severity, or duration to result in a greater degree of occupational and social impairment than as contemplated by the currently assigned 70 percent rating. Further, all of the VA and private medical records from this time period indicate that the Veteran's hygiene and grooming were appropriate. Moreover, the record shows that the Veteran reconciled with his spouse, maintained a positive relationship with his children, and attended Patriots and Paws. Furthermore, while he was not working during the appeal period, which he attributed to PTSD-related symptoms during his VA examinations, his VA treatment records reflect his desire to obtain his MBA, his plan to pursue acting/theater in a different city, and his report that he lost his last job due to family issues unrelated to his PTSD. Moreover, in consideration of the totality of the Veteran's PTSD symptomatology, the June 2018, October 2019, and July 2021 VA examiners, psychologists who have the necessary expertise to evaluate psychiatric disabilities, determined that such resulted in, at most, in occupational and social impairment with deficiencies in most areas, which is commensurate with a 70 percent rating under the General Rating Formula. Thus, the Board finds that, as the probative evidence of record does not show that the Veteran's PTSD resulted in total occupational and social impairment for the appeal period beginning June 20, 2018, a rating in excess of 70 percent for such disability is not warranted. 2. Entitlement to a rating in excess of 10 percent for status post left wrist fracture, healed, with residual mild chronic tendonitis. For the entire appeal period, the Veteran's left wrist disability has been rated as 10 percent disabling. However, he contends that he is entitled to a higher rating due to pain and limitation of wrist motion. Specifically, at the November 2020 Board hearing, the Veteran indicated that he experienced a lot of pain when attempting to bend his wrist into a pushup position, had stiffness where he could hardly move his wrist for a few days, and had difficulty with pulling, repeated motions, and doing a full range of motion with his left thumb. Here, the Veteran has consistently reported that he is right-hand dominant. As such, the ratings for the minor side are applicable. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, such is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). In the instant case, the record reflects that the Veteran's left wrist was examined by VA in February 2016. With respect to Correia, the Board observes that range of motion testing on passive motion, or in weight-bearing and nonweight-bearing was not conducted. Further, the February 2016 VA examiner did not provide information regarding the additional loss of range of motion that may be present during the Veteran's reported flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). However, the July 2021 VA examination fully complied with the Court's holdings in such cases. Moreover, the Veteran is in the receipt of the maximum schedular rating based on limitation of wrist motion and no higher rating is warranted without evidence of ankylosis. Consequently, there is no prejudice to the Veteran in the Board proceeding with a decision at the present time. The Veteran's left wrist disability has been evaluated pursuant to DC 5024-5215 for the entire appeal period. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. The Board observes that, in the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. In this case, the hyphenated diagnostic code indicates tenosynovitis rated under DC 5024 is the service-connected disorder and the residual symptom of limitation of motion of the wrist is rated under DC 5215. 38 C.F.R. § 4.71a. Specifically, pursuant to DC 5024, tenosynovitis is rated based on limitation of the affected parts as degenerative arthritis, which is evaluated under DC 5003. Degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. DC 5003 further provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. In the absence of limitation of motion, DC 5003 provides for a 10 percent rating with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating under DC 5003 requires involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. In Notes (1) and (2) in DC 5003, it is indicated these 20 and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, DC 5003. Under 38 C.F.R. § 4.45(f) for the purpose of rating a disability based on arthritis, the only major joints are the shoulder, elbow, wrist, hip, knee and ankle. Additional groups of multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints, ratable on parity with major joints. 38 C.F.R. § 4.45 (f); Spicer v. Shinseki, 752 F.3d 1367, 1371 (Fed. Cir. 2014) (when DC 5003 is read in view of § 4.45(f), it is clear that DC 5003 requires limitation of motion in two or more interphalangeal joints to warrant a 10 percent rating). Normal range of motion of the wrist includes dorsiflexion (extension) from zero to 70 degrees, palmar flexion from zero to 80 degrees, ulnar deviation from zero to 45 degrees, and radial deviation from zero to 20 degrees. 38 C.F.R. § 4.71a, Plate I. Under DC 5215, the sole and maximum evaluation of 10 percent is assigned for limitation of (major or minor) wrist motion, where dorsiflexion is less than 15 degrees, or palmar flexion is limited in line with the forearm. The Board acknowledges that the regulations for rating orthopedic disabilities were recently amended as of February 2021; however, as the rating criteria under DCs 5024 and 5215 were not altered, the Veteran will be evaluated under the same criteria in the instant rating analysis, regardless of whether the old or new regulations are applied. As noted previously, the Veteran was afforded a VA examination in February 2016, at which time he reported experiencing left wrist pain and stiffness. On physical examination, the Veteran's left wrist range of motion was normal in all planes despite experiencing pain with palmar flexion, dorsiflexion, ulnar deviation, and radial deviation. The Veteran was able to complete multiple range of motion exercises, and the examiner noted that there was additional loss of function or range of motion following three repetitions due to pain. Specifically, the Veteran's left wrist range of motion reflected dorsiflexion to 65 degrees, palmar flexion to 75 degrees, ulnar deviation to 40 degrees, and radial deviation to 20 degrees. The examiner further noted that pain and lack of endurance significantly limited functional ability with repeated use over a period of time. Here, the Veteran's left wrist range of motion reflected dorsiflexion to 60 degrees, palmar flexion to 70 degrees, ulnar deviation to 35 degrees, and radial deviation to 15 degrees. The Veteran also reported flare-ups of his left wrist disability manifested by pain in activities such as repetitive typing, forceful pushing and pully, and heavy lifting and carrying. There was no evidence of ankylosis. On VA examination in July 2021, the Veteran reported experiencing dull to sharp left wrist pain, stiffness, and lack of mobility. On physical examination, the Veteran's left wrist range of motion reflected dorsiflexion to 70 degrees, palmar flexion to 70 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. The examiner stated that the Veteran's limitation of motion did not contribute to a functional loss. The Veteran exhibited pain with dorsiflexion and palmar flexion; and passive range of motion was the same as active. However, the Veteran was able to complete multiple range of motion exercises, and the examiner noted that there were no additional limitations by pain, fatigue, weakness, or lack of endurance following repetitions, with repeated use over time, or with flare-ups. In this regard, the Veteran reported flare-ups of his left wrist disability that were severe, lasted for days, occurred weekly, and were precipitated by overuse. There was no evidence of ankylosis. After a careful review of the record, the Board finds that an initial rating in excess of 10 percent for the Veteran's left wrist disability is not warranted pursuant to DC 5024-5215. In this regard, the Board notes that he has been assigned the sole and maximum evaluation under DC 5215 in contemplation of pain and limitation of motion. Thus, a rating higher than 10 percent is not available under DC 5215. Moreover, a rating in excess of 10 percent for the Veteran's left wrist disability is not warranted pursuant to DC 5003 as there is no evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. The Board has also considered whether a higher or separate rating is warranted under any other potentially applicable DCs. In this regard, a higher disability evaluation is afforded for ankylosis of the wrist under DC 5214. Ankylosis is immobility and consolidation of a joint due to disease, injury or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 46 (1993); Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). However, while the Veteran has limitation of motion of his left wrist, it is not shown to be ankylosed as he is still capable of movement of such joint, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, and incoordination, or as a result of repetitive motion and/or flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, supra; Mitchell, supra. Therefore, a higher or separate rating based on ankylosis is not warranted. Other Considerations In reaching its conclusions, the Board acknowledges the Veteran's belief that his symptoms related to his PTSD and left wrist disability are more severe than as reflected by the currently assigned ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical question). The Board finds the medical evidence in which professionals with medical expertise examined the Veteran in regard to his PTSD and left wrist disability, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of such disabilities. The Board has also considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran's service-connected PTSD and left wrist disability; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such disabilities is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In conclusion, the Board finds that increased ratings for the Veteran's PTSD and left wrist disability are not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeal and his increased rating claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Koria B. Stanton, 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.