Citation Nr: 21007803 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 16-19 364 DATE: February 10, 2021 ORDER A 70 percent disability rating for service-connected posttraumatic stress disorder (PTSD) prior to May 31, 2016, is granted. A disability rating greater than 70 percent for service-connected PTSD, from September 1, 2016, is denied. A disability rating greater than 10 percent for service-connected traumatic arthritis of the left knee manifested by limitation of extension prior to December 4, 2019, is denied. A disability rating greater than 30 percent for service-connected traumatic arthritis of the left knee manifested by limitation of extension from December 4, 2019, is denied. An increased 20 percent disability rating for service-connected traumatic arthritis of the left knee, status post multiple meniscectomies, from September 14, 2012, is granted (under Diagnostic Code 5258 in lieu of the 10 percent previously assigned under Diagnostic Code 5259). A separate 20 percent disability rating for service-connected traumatic arthritis of the left knee manifested by lateral instability, from September 14, 2012, is granted. A separate noncompensable disability rating for service-connected left knee scars associated with traumatic arthritis of the left knee, from September 14, 2012, is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU), prior to May 31, 2016, is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether prior to May 31, 2016, the Veteran’s PTSD symptoms and overall impairment more nearly approximated occupational and social impairment with deficiencies in most areas; however, they have not more nearly approximated total occupational and social impairment. 2. From September 1, 2016, the Veteran’s PTSD results in deficiencies in most areas, but not total occupational and social impairment. 3. Prior to December 4, 2019, the Veteran’s traumatic arthritis of the left knee was manifested by no more than zero degrees of extension and 95 degrees of flexion. 4. From December 4, 2019, the Veteran’s traumatic arthritis of the left knee was manifested by no more than 20 degrees of extension and 80 degrees of flexion. 5. From September 14, 2012, the Veteran’s traumatic arthritis of the left knee, status post multiple meniscectomies, has been manifested by dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 6. From September 14, 2012, the Veteran’s traumatic arthritis of the left knee has been manifested by moderate lateral instability. 7. From September 14, 2012, the Veteran’s left knee scars associated with traumatic arthritis of the left knee were not painful and/or unstable, or of a total area greater than 39 square centimeters (six square inches). CONCLUSIONS OF LAW 1. The criteria for a 70 percent disability rating for service-connected PTSD, prior to May 31, 2016, have been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a disability rating greater than 70 percent for service-connected PTSD, from September 1, 2016, have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for a disability rating greater than 10 percent for service-connected traumatic arthritis of the left knee manifested by limitation of extension prior to December 4, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 4. The criteria for a disability rating greater than 30 percent for service-connected traumatic arthritis of the left knee manifested by limitation of extension from December 4, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 5. The criteria for an increased disability rating of 20 percent, but no higher, for service-connected traumatic arthritis of the left knee, status post multiple meniscectomies, from September 14, 2012, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258 (in lieu of Diagnostic Code 5259). 6. The criteria for a separate 20 percent disability rating for service-connected traumatic arthritis of the left knee manifested by lateral instability, from September 14, 2012, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 7. The criteria for a separate noncompensable disability rating for service-connected left knee scars associated with traumatic arthritis of the left knee, from September 14, 2012, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7802. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1982 to June 1992 with additional service in the Air National Guard. His decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from December 2014 and March 2015 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO), in Jackson, Mississippi. In May 2019, the Veteran testified at a video conference hearing over which the undersigned presided. A transcript of the hearing is of record. This matter was previously before the Board in October 2019 at which time it was remanded for additional development. It is now returned to the Board. During the pendency of the appeal, by rating action dated in September 2020, the RO determined that the service-connected traumatic arthritis of the left knee warranted a 30 percent disability rating, effective as of December 4, 2019. The RO also determined that the service-connected PTSD warranted a 70 percent disability rating, effective as of September 1, 2016. The RO, in pertinent part, also granted separate service connection for traumatic arthritis of the left knee, status post multiple meniscectomies, and for left knee scars, and awarded a TDIU, effective as of May 31, 2016. A claimant seeking a disability rating greater than assigned will generally be presumed to be seeking the maximum benefit allowed by law and regulation. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran has not withdrawn the appeals as to the issues of disability ratings greater than assigned, thus, they remain in appellate status. Increased Disability Ratings Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement that affects stability, standing, and weight-bearing. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Consideration must include joint testing for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the diagnostic code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, will only be considered in conjunction with diagnostic code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 1. Entitlement to a disability rating greater than 50 percent for service-connected PTSD prior to May 31, 2016. 2. Entitlement to a disability rating greater than 70 percent for service-connected PTSD from September 1, 2016. The Veteran asserts that his service-connected PTSD is more disabling than reflected by the respective 50 and 70 percent disability ratings. Service connection for PTSD was established by rating action dated in September 2007 at which time an initial 10 percent disability rating was assigned effective as of June 1, 2006. In September 2012, the Veteran filed a claim for an increased disability rating. By rating action dated in May 2013, the RO determined that the service-connected PTSD warranted a 50 percent disability rating, effective as of September 14, 2012, the date of receipt of his claim for an increased disability rating. In September 2016, the RO determined that the Veteran’s disability warranted a temporary total disability rating from May 31, 2016, to August 31, 2016, as a result of inpatient treatment for the PTSD. In September 2020, the RO assigned a 70 percent disability rating for the PTSD, effective as of September 1, 2016. The Veteran’s service-connected PTSD is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. This disability is rated under the General Rating Formula for Mental Disorders, which provides as follows: A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. A 70 percent disability rating 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; 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 work like setting); inability to establish and maintain effective relationships. A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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, 442 (2002). In adjudicating a claim for an increased disability rating, the adjudicator must consider all symptoms of a claimant’s service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The amendments replace those references with references to the recently updated Fifth Edition (DSM-V). As the Veteran’s claim was received prior to August 4, 2014, but had not yet been certified to the Board, the DSM-IV is applicable to this case. However, according to the new DSM-V, clinicians do not typically assess Global Assessment of Functioning (GAF) scores. The DSM-V introduction states that it was recommended that the GAF be dropped from DSM-V for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In reviewing the evidence of record, the Board will consider any assigned GAF score; however, the Board is cognizant that GAF scores are not, in and of themselves, the dispositive element in rating a disability. Rather, GAF scores must be considered in light of the actual symptoms of the Veteran’s disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126 (a). The GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). According to the DSM-IV, which VA had adopted pursuant to 38 C.F.R. §§ 4.125 and 4.130, a GAF score of 41 to 50 is reflective of 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). A GAF score ranging from 51 to 60 reflect more 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). A GAF of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. During the May 2019 Board hearing, the Veteran endorsed a history of experiencing anxiety, isolation, depression, sleep disturbance, homicidal and suicidal ideations, panic attacks, paranoia, irritability, and anger. A VA examination report dated in May 2013 shows that the Veteran was diagnosed with PTSD and recurrent, moderate, major depressive disorder. A GAF of 65 was assigned. It was not possible to differentiate the symptoms between the Veteran’s two diagnoses. The level of occupational and social impairment was described as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Symptoms that applied to the Veteran’s diagnosis included depressed mood, anxiety, chronic sleep impairment, disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner added that the Veteran’s symptoms including recurrent memories and dreams of combat in Iraq in which he saw enemy soldiers killed and had his vehicle often struck by small arms fire; psychological distress when exposed to situations reminding him of these stressors; strategic avoidance; social estrangement; irritability; hypervigilance; and recurrent, moderate, major depressive disorder caused occasional social impairment and intermittent inability to perform occupational tasks. A VA outpatient treatment record dated in January 2014 shows that the Veteran sought treatment as a walk-in. He was said to be attentive and sharing. His speech was normal. He denied suicidal or homicidal ideations. He admitted he had not been taking his medications as prescribed. He reported that he was not sleeping. He recently stayed up a couple of days just sitting, watching the ceiling fan. He stated he had stayed inside since New Year’s Eve. He indicated that he had had crying spells at least two times a week for the last four months. He described his concentration and memory as poor. His appetite was poor. He would hear noise and sometimes sees movement out of the corner of his eye, but no one would be there. He would struggle with anger. He had been arrested for physical altercations. He added that observers told him he had his cousin by the neck and threw him through a door. He had been physical with his significant other. He would have intrusive thoughts about explosions, mines, and other combat related themes. He reports about 70 percent of sleep disturbance had to do with traumatic experiences manifested in dreams, avoidance of sleep, and fear. He denied alcohol or drug use. He had family support and a stable work history. He had a religious affiliation. He had disengaged from his social network. He had loss interest in things he once enjoyed, such as music and reading. The Veteran was offered resources for assistance. He was said to be stable. A VA outpatient treatment record dated in February 2014 shows that the Veteran presented for a scheduled appointment. He indicated that he had been feeling about the same. He endorsed avoidance, wanting to be by himself. He would experience depression, but denied auditory or visual hallucinations. He denied suicidal or homicidal ideations. He was getting little to no sleep. He would have nightly nightmares about combat or about relatives that had passed. He would be afraid to go to sleep. He would experience anxiety. He would avoid crowds, choosing to isolate. He described a history of paranoia, hypervigilance, and irritability. He denied alcohol or illicit drug use. He continued to have intrusive memories of his combat mission, having seen plenty of dead bodies. He was single, had two children, and lived with his daughter and granddaughter. He reported having a significant other. Mental status examination revealed that he was casually dressed and fairly groomed. He was alert and oriented to person, place, and time. Mood was appropriate, and affect was congruent to mood. Speech was normal. Thought process was coherent without any flight of ideas or loose associations. There were no suicidal or homicidal ideations. There were no delusions or auditory or visual hallucinations. The diagnosis was PTSD, and a GAF score of 55 was assigned. A VA examination report dated in April 2014 shows that the Veteran was diagnosed with PTSD and recurrent, moderate, major depressive disorder. The examiner was said to be in agreement with the May 2013 as to the level of the Veteran’s impairment. The level of occupational and social impairment was described as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Symptoms that applied to the Veteran’s diagnosis included depressed mood, anxiety, chronic sleep impairment, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner added that the Veteran’s intellect was within high average, and that he had a college degree. Despite his high intellect, he produced an exaggerated/invalid Minnesota Multiphasic Personality Inventory (MMPI). The PTSD was said to be mild, and certainly did not preclude gainful employment. Disputes, disagreements, and fights were not caused by PTSD. A private medical record from W. S. Cook, Jr., M.D., a Board Certified Psychiatrist, dated in June 2014, shows that the Veteran presented clean in appearance, courteous, and cooperative. He was alert and attentive. His speech was audible and intelligible. Mood appeared to be anxious with an appropriate affect. He was not acutely suicidal or homicidal or hallucinating at this time. He seemed to be a reliable informant. His level of intelligence was estimated to be in the average range. His recall of remote events was good as evidenced by his ability to recall events from the past. His recall of recent events was good as evidenced by his ability to recall 2/3 objects at five minutes. Immediate recall was fair as evidenced by his ability to recall 5/5 digits forward and 3/5 digits backward. Thought processes were generally coherent and goal directed. There was no evidence of obsessions, ideas of reference paranoia, or delusions. He acknowledged that he had friends, but typically did not socialize. Judgment seemed good. Insight regarding mental problems seemed fair. He denied childhood sexual or physical abuse. Concentration was poor. He had difficulty performing simple math. Pace of response was average. Persistence was good. When questioned about why he believed he could not work, he referenced his attitude and anger. The most apparent diagnosis was said to be PTSD, with psychological disorder associated with chronic pain syndrome and personality disorder. Dr. Cook added that his ability to perform routine, repetitive work related tasks seemed very doubtful. His ability to interact satisfactorily with others, including coworkers and supervisors seemed very poor. Correspondence from the Veteran’s VA Mental Health Treatment Coordinator, dated in March 2015, shows that he was being treated for PTSD. He was said to have been undergoing treatment since October 15, 2012, and that it was not thought that he was able to perform gainful employment due to his physical and mental disabilities. A lay statement from M. B., a former work supervisor of the Veteran, received in April 2015, shows that he was said to have been employed with U-Haul for only a few months. The Veteran was said to have initially exhibited a good work ethic and customer service skills, but began experiencing behavior changes. He became withdrawn and unable to complete assigned tasks. He would forget and would exhibit poor concentration. He became irritable, moody, and extremely rude to customers. When counseled, he became hostile and verbal. He was allowed to resign due to medical/personal reasons. A lay statement from the Veteran’s parents, received in April 2015, shows that he was said to have exhibited severe behavior changes. He was unable to rest or sleep well. He would not interact with his family, friends, or people in general. He always wanted to be alone. He would avoid crowds. He reported concentration and memory issues, insomnia, fatigue, restlessness, irritability, anxiety, depression, headaches, muscle symptoms, gastrointestinal symptoms, disorientation, PTSD, very disturbing nightmares, loneliness, and unwarranted temper flares with thoughts of harming someone. He would stay deeply angry, in a volatile state. A lay statement from the Veteran’s sister, received in April 2015, shows that he was said to have experienced difficulty functioning in life since active service. He was would experience severe depression, sleep disturbance, isolation, and poor personal hygiene. He was said to appear distant, disoriented, and angry. His communication with the family had diminished and his memory skills were failing. VA outpatient treatment records dated through May 2016 show that the Veteran continued to receive ongoing symptoms associated with his PTSD that were consistent with those as set forth above. On May 31, 2016, he was admitted to a VA Trauma Recovery Residential Program lasting until August 23, 2016. The Veteran’s GAF scores prior to May 30, 2016, have ranged from 55 to 65. These findings are indicative of a description of symptoms that have ranged from mild to serious with mild to serious impairment in social and occupational functioning. In light of the broad range of GAF scores provided, the Board will place greater weight on the objective facts than on the subjective GAF scores. In this regard, it is the impact of the Veteran’s psychiatric symptomatology on his occupational and social functioning that is the ultimate consideration. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Here, the range of GAF scores cannot, in and of themselves, establish the precise level of occupational and social impairment. The overall evidence of record has demonstrated that the Veteran has consistently experienced ongoing depression, anxiety, sleep disturbance, nightmares, insomnia, hypervigilance, irritability, avoidant behavior, intrusive thoughts, impaired memory, impaired impulse control, and anxiety. He has also on occasion endorsed visual and auditory hallucinations, and homicidal and suicidal ideations. In order to meet the criteria for a 70 percent disability rating, the Veteran’s disability would have to be manifested primarily by occupational and social impairment, with deficiencies in most areas due to symptoms such as suicidal ideation; obsessional rituals; intermittently illogical speech; near-continuous panic or depression; 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; and an inability to establish and maintain effective relationships. In this regard, the Veteran has exhibited near-continuous depression affecting his ability to function, unprovoked irritability, a neglect of personal hygiene, impaired impulse control, difficulty in adapting to stressful circumstances, and difficulty establishing and maintaining effective relationships. Although he did not exhibit all of the symptomatology consistent with a 70 percent disability rating, resolving all doubt in favor of the Veteran, the Board finds that overall, his disability picture over the entire course of the appeal meets the criteria for a 70 percent disability rating. See Mauerhan, 16 Vet. App. at 442. The Board has additionally reviewed the evidence to determine if a disability rating in excess of 70 percent may be assigned. A 100 percent disability rating for PTSD requires symptoms more nearly approximating total occupational and social impairment. The preponderance of the evidence of record demonstrates that the Veteran is not entitled to a 100 percent disability rating prior to May 31, 2016, as the evidence does not show symptoms and overall impairment more nearly approximating total occupational and social impairment before then. In sum, considering all applicable rating criteria, the Board finds that the level of impairment presented by the Veteran’s service-connected PTSD over the course of this appeal prior to May 31, 2016, warrants a 70 percent disability rating, and no higher. Accordingly, the Board finds that the overall disability picture most closely approximates the criteria for a 70 percent disability rating prior to May 31, 2016. Consideration has been given to additional staged ratings since the date of the Veteran’s claim (i.e., different percentage ratings for different periods of time). See Fenderson, 12 Vet. App. at 119. There, however, appears to be no identifiable period of time since the date of claim during which an additional staged rating for the PTSD would be warranted. The discharge summary from the VA Trauma Recovery Residential Program dated August 23, 2016, shows that the Veteran, in pertinent part, was diagnosed with chronic PTSD. He was assigned a GAF of 59. Mental status examination at discharge revealed that he was alert and oriented. He was casually dressed and fairly well groomed. Mood was appropriate, and affect was congruent to mood. Speech was normal. Thought process was coherent without any flight of ideas or loose associations. Thought content revealed no suicidal or homicidal ideations, delusions, or auditory or visual hallucinations. Concentration, attention, insight, and judgment were intact. VA outpatient treatment records dated through September 2020 show that the Veteran continued to receive ongoing symptoms associated with his PTSD that were consistent with those as set forth above. A VA examination report dated in December 2019 shows that the Veteran was diagnosed with PTSD. His level of occupational and social impairment was described as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Symptoms that were said to apply to the PTSD diagnosis included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. He presented in clean, casual clothes. He walked with the aid of a cane. He was engaged, cooperative, and very polite. Affect was blunted. Mood was “a little funky, mad, agitated.” He stated that he felt similarly most days. Irritability made it difficult to get along with peers and accept supervision. Sleep deprivation made it difficult to focus and increased irritability. Depression caused anhedonia and a lack of energy which interfered with starting or completing tasks. Difficulty concentrating made it difficult to focus and difficult to finish tasks. Memory issues made it difficult to recall information needed to finish tasks and at times added to difficulty remembering what task was at hand and needed attention. Having carefully considered the evidence of record from September 1, 2016, the Board finds that the overall evidence has demonstrated that the Veteran has consistently experienced ongoing depression, anxiety, sleep disturbance, nightmares, insomnia, irritability, avoidant behavior, intrusive thoughts, and impaired memory. In order to meet the criteria for a 70 percent disability rating, his disability would have to be manifested primarily by occupational and social impairment, with deficiencies in most areas due to symptoms such as suicidal ideation; obsessional rituals; intermittently illogical speech; near-continuous panic or depression; 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; and an inability to establish and maintain effective relationships. In this regard, he has exhibited suicidal ideation, near-continuous depression affecting his ability to function, irritability, and difficulty establishing and maintaining effective relationships. Although he has not exhibited all of the symptomatology consistent with a 70 percent disability rating, overall, his disability picture over this period on appeal meets the criteria for a 70 percent disability rating. See Mauerhan, 16 Vet. App. at 442. The preponderance of the evidence of record, however, demonstrates that the Veteran is not entitled to a 100 percent disability rating as the evidence does not show that the symptoms or overall level of impairment more nearly approximate total occupational and social impairment. While the Veteran’s symptoms may have worsened throughout the appeal period, they have never consistently risen to the level that would warrant the assignment of a 100 percent disability rating. The above evidence reflects that the Veteran’s PTSD has not caused gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; or disorientation to time or place. Moreover, the Veteran has apparently maintained a good relationship with his immediate family. Thus, total impairment is not demonstrated. In sum, considering all applicable rating criteria, the Board finds that the level of impairment presented by the Veteran’s service-connected PTSD over the course of this period on appeal warrants the currently assigned 70 percent disability rating, and no higher. For the foregoing reasons, the Board finds that the criteria for the next higher 100 percent disability rating have not been met. The Board has considered the statements of the Veteran as to the extent of his current symptoms. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. The Board finds that the preponderance of the evidence is against the assignment of any higher rating from September 1, 2016, and the claim for increased disability rating must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to a disability rating greater than 10 percent for service-connected traumatic arthritis of the left knee, manifested by limitation of extension, prior to December 4, 2019. 4. Entitlement to a disability rating greater than 30 percent for service-connected traumatic arthritis of the left knee, manifested by limitation of extension, from December 4, 2019. 5. Entitlement to an initial disability rating greater than 10 percent for service-connected traumatic arthritis of the left knee, status post multiple meniscectomies. 6. Entitlement to a separate disability rating for service-connected traumatic arthritis of the left knee manifested by lateral instability. 7. Entitlement to a separate initial compensable disability rating for service-connected left knee scars associated with traumatic arthritis of the left knee. The Veteran asserts that his service-connected left knee disability is more disabling than reflected by the currently assigned respective disability ratings. Service connection for the left knee disability was established by rating action dated in July 1992 at which time an initial 10 percent disability rating was assigned effective as of June 18, 1992. In September 2012, the Veteran filed a claim for an increased disability rating. By rating action dated in September 2020, the RO determined that the service-connected traumatic arthritis of the left knee, manifested by limitation of extension, warranted a 30 percent disability rating, effective as of December 4, 2019. The RO also granted separate service connection for traumatic arthritis of the left knee, status post multiple meniscectomies (rated at 10 percent), and for left knee scars (rated as noncompensable), effective as of October 2, 2013. The Veteran’s left knee disabilities have each been rated separately by the RO under Diagnostic Codes 5259 (symptomatic removal of semilunar cartilage), 5261 (limitation of extension), and 7802 (scar, not of the head, face, or neck). Disabilities of the knee are governed by 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263. Diagnostic Code 5256 provides the rating criteria for ankylosis of the knee, which ranging from 30 to 60 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Diagnostic Code 5257 provides ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee that is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5258 provides the rating criteria for dislocation of semilunar cartilage and Diagnostic Code 5259 provides the rating criteria for symptomatic removal of semilunar cartilage. Under Diagnostic Code 5258, a 20 percent disability rating is warranted when there is dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Under Diagnostic Code 5259, a 10 percent disability rating is warranted for symptomatic removal of the semilunar cartilage. Diagnostic Code 5260 provides the criteria for limitation of knee flexion of the knee. Under this diagnostic code provision, a 30 percent disability rating is assigned where flexion is limited to 15 degrees; a 20 percent disability rating is assigned where flexion is limited to 30 degrees; a 10 percent disability rating is assigned where flexion is limited to 45 degrees; and a noncompensable disability rating is assigned where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 governs limitation of extension and provides for a noncompensable disability rating for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for a limitation to 15 degrees, 30 percent for a limitation to 20 degrees, 40 percent for extension limited to 30 degrees, and a maximum of 50 percent for a limitation to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5262 provides the rating criteria for impairment of the tibia, ranging from and fibula, ranging from 10 to 40 percent. Diagnostic Code 5263 provides the criteria for genu recurvatum, at 10 percent. 38 C.F.R. § 4.71a, Diagnostic Codes 5262, 5263. Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints or joint involved; in this case Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. If a compensable degree of limitation of motion is not attainable under the relevant rating criteria, then Diagnostic Code 5003 provides for a 10 percent rating for each such major joint or group of minor joints affected by limitation of motion. In that event, the limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997), VA’s General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Code 5003-5010 (for the arthritis) and Diagnostic Code 5257 (for the instability) based on additional disability. It was specified that, for a knee disorder already rated under Diagnostic Code 5257, a claimant would have additional disability justifying a separate rating if there is limitation of motion under Diagnostic Code 5260 (flexion) or Diagnostic Code 5261 (extension). Hence, if a claimant has a disability rating under Diagnostic Code 5257 for instability of the knee and there is also X-ray evidence of arthritis and resulting limitation of motion, a separate rating is available under Diagnostic Code 5003-5010. Likewise, if a claimant has a disability rating under Diagnostic Code 5003 for arthritis of the knee, and there is evidence of instability, a separate rating is available under Diagnostic Code 5257. See VAOPGCPREC 9-98 (August 14, 1998) (clarifying that, to receive separate ratings on this basis, the Veteran must at least have sufficient limitation of motion to meet the threshold minimum requirements for a zero percent rating under either Diagnostic Code 5260 or 5261, for flexion or extension respectively, or have pain causing additional limitation of motion to at least these extents). It is also possible to receive separate ratings for limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) for disability of the same joint. See VAOPGCPREC 9-2004 (Sept. 17, 2004). During the May 2019 Board hearing, the Veteran indicated that his left knee would constantly give out, lock, and pop. He described constant extreme throbbing pain. He reported that he had to wear a knee brace because he his meniscus had been removed, he had no cartilage left, and his knee joint was bone on bone. A VA examination report dated in April 2013 shows that the Veteran was diagnosed with traumatic arthritis of the left knee with multiple meniscectomies, and chondromalacia of the left knee. The Veteran described that both knees would swell, and that the left knee would periodically feel hot. There was no redness, but the knee would lock up and give way at times. There were no fracture, dislocation, or subluxation. The knee would stiffen during the day. Physical examination revealed range of motion of the left knee was 115 degrees of flexion, with pain starting at 110 degrees, and zero degrees of extension with no objective evidence of painful motion. Following repetitive motion, range of motion in the knee was unchanged. Functional loss of the knee was described as less movement than normal and pain on movement. There was no ankylosis. There was tenderness or pain to palpation. There was no history of recurrent patellar subluxation or dislocation. A history of shin splints and stress fracture during active duty was reported, but no current symptoms. There was a history of meniscal conditions and meniscal surgery for a meniscal tear and frequent episodes of joint pain. There was a history of meniscectomy and also chondromalacia debridement. The Veteran had surgical scars, but they were not painful and/or unstable, or of a total area greater than 39 square centimeters (six square inches). The Veteran used a hard knee brace regularly and a cane occasionally. The left knee disability was said to impact the Veteran’s ability to work. He had been working in law enforcement, but the physical tests were too problematic for him to complete. He was able to walk and could work in a partially sedentary job due to the knee. DeLuca provisions regarding functional capacity during flare-ups could not be clearly delineated by the examiner without resorting to speculation. A VA examination report dated in May 2014 shows that the Veteran was diagnosed with traumatic arthritis of the left knee with multiple lateral meniscectomies, and osteoarthritis of the left knee. The Veteran described that his left knee would swell, and become stiff, red, and warm at times. It would periodically lock up and give way. He denied any clicking, fracture, subluxation, dislocation, or other complaints. He indicated that his symptoms would flare-up three to four times per week, with pain reaching a level of nine on a scale of 10. Pain would be worse with prolonged walking, standing, sitting, swimming, or almost anything. Pain would be relieved with ice and medication. Physical examination revealed range of motion of the left knee was 100 degrees of flexion, with pain starting at 90 degrees, and zero degrees of extension with pain starting at five degrees. Following repetitive motion, range of motion in the knee was unchanged. Functional loss of the knee was described as less movement than normal and pain on movement. There was no ankylosis. There was tenderness or pain to palpation. Stability testing was within normal limits. There was no history of recurrent patellar subluxation or dislocation. A history of shin splints during active duty was reported, but no current symptoms. There was a history of meniscal conditions and meniscal surgery for a meniscal tear and frequent episodes of joint pain. There was a history of meniscectomy and also chondromalacia debridement. The Veteran had surgical scars, but they were not painful and/or unstable, or of a total area greater than 39 square centimeters (six square inches). Pain was said to be related to arthritic changes. The Veteran used a hard knee brace regularly for stability and a cane occasionally. The left knee disability was said to impact the Veteran’s ability to work. The knee disability was said to limit his employment as a laborer, but other options would be available that would include a more sedentary work style. DeLuca and Mitchell provisions regarding functional capacity during flare-ups and repeated use over time could not be clearly delineated by the examiner without resorting to speculation. A VA examination report dated in June 2015 shows that the Veteran was diagnosed with traumatic arthritis of the left knee. He reported constant pain in the knee. He rates the pain as a level eight to nine on a scale of 10, but would flare daily to a 10. He stated the pain was aggravated with most activity. Treatment was with rest, medication, and ice. Physical examination revealed range of motion of the left knee was 100 degrees of flexion and zero degrees of extension with pain noted but not resulting in functional loss. There was evidence of pain with weight-bearing. There was tenderness or pain to palpation on both the medial and lateral aspects of the patella. There was no evidence of crepitus. Repetitive use testing was not conducted, and functional loss thereafter could not be determined without resorting to speculation. The examination was not being conducted during a flare-up. Mitchell provisions regarding functional capacity following repeated use over time could not be clearly delineated by the examiner without resorting to speculation. Muscle strength and stability testing were within normal limits. There was no ankylosis. There was a history of meniscal conditions and meniscal surgery for a meniscal tear and frequent episodes of joint pain. There was a history of meniscectomy. There were no scars identified. The Veteran used a knee brace regularly. The functional impact of the left knee disability was described as difficulty walking long distances, walking up or down long stairs, walking over uneven terrain, squatting or kneeling. This would not preclude sedentary employment. A VA examination report dated in July 2018 shows that the Veteran was diagnosed with left knee meniscal tear, knee joint osteoarthritis, and degenerative arthritis. A history of multiple lateral meniscus debridement and meniscectomy procedures was indicated. The Veteran reported that going up and down stairs was troublesome for his knee. He described constant sharp pain and fullness of the left knee. He would have daily stiffness and swelling, as well as frequent popping of the left knee. The knee would give way often with the joint giving way to the anterior direction. No falls were recalled. He denied any left knee locking, fracture, subluxation, dislocation, or other complaints. With regard to flare-ups, he described his pain as every day, 24 hours per day, of varying degrees. He would use pain medication, elevation, and alternate hot and cold. He would also use a transcutaneous electrical nerve stimulation (TENS) unit. The functional impact was described as a walking about 50 yards, then having to stop for about 15 minutes before continuing. He would exercise very little. Sitting down was limited to about 30 minutes, then he must stand up. Physical examination revealed range of motion of the left knee was 95 degrees of flexion and four degrees of extension with objective evidence of pain noted. There was no evidence of pain with weight-bearing or with non-weight-bearing. There was tenderness and pain to palpation on both the medial and lateral aspects of the patella. There was evidence of crepitus. There was no additional functional or range of motion following repetitive use testing. Functional loss after repeated use over time could not be determined without resorting to speculation. The examination was not being conducted during a flare-up, and functional capacity could not be clearly delineated by the examiner without resorting to speculation. Muscle strength and stability testing were within normal limits. There was no ankylosis. There was a history of meniscal conditions and meniscal surgery, no remaining. Gait appeared antalgic and without pain. He was able to perform heel walk, toe walk, and toe-heel walk without pain or difficulty. The Veteran had surgical scars, but they were not painful and/or unstable, or of a total area greater than 39 square centimeters (six square inches). He would use bilateral metal-sided knee braces most of every day when awake. He would occasionally use a cane, but did not bring it with him. He added that he had a walker for the preceding three years for his knees but would rarely use it. The examiner indicated that based on left knee only, the Veteran should be capable of working in a sedentary or mostly sedentary job. He would have no difficulty answering telephone for example. He should have no difficulty lifting and carrying light weights for relatively short distances for no more than two hours each work day, with bulk of the day spent seated; out of an eight hour work day, this amounts to about 75 percent of time seated, with remaining about 25 percent of time spent in some combination of standing or walking. A VA examination report dated in December 2019 shows that the Veteran was diagnosed with left knee traumatic arthritis post multiple meniscectomies. The Veteran reported current left knee symptoms that included chronic, constant, severe shooting and throbbing pain; frequent locking; severe swelling; instability; and difficulty sleeping due to severe pain. Functional impairment was described as difficulty sitting or standing for long periods of time without rest; difficulty going up or down steps or stairs; and difficulty walking on uneven surfaces. Physical examination revealed range of motion of the left knee was 90 degrees of flexion and 20 degrees of extension with objective evidence of pain. There was evidence of pain with weight-bearing and evidence of crepitus. There was tenderness and pain to palpation, with guarding of the left anterior knee and lateral knee described as moderately severe. Repetitive use testing could not be conducted safely. Functional loss after repeated use over time was predicted to include pain, fatigue, weakness, and lack of endurance. Range of motion was predicted to be from 20 degrees of extension to 80 degrees of flexion following repeated use over time or during a flare-up. Additional contributing factors of disability were said to include less movement than normal due to ankylosis, adhesions, etc.; instability of station; disturbance of locomotion; interference with sitting; interference with standing; difficulty sitting or standing for long periods of time without rest; difficulty going up or down steps or stairs; and difficulty walking uneven surfaces. Muscle strength testing revealed active movement against some resistance. There was no atrophy or ankylosis. There was moderate effusion with flare-ups. There was a history of moderate lateral instability. There was a history of meniscus condition. There were frequent episodes of joint locking, joint pain, and joint effusions. Residuals of the multiple left knee surgeries (dated in 1989, 1992, 2000, and 2001) were said to include pain, loss of range of motion, weakness, locking, and history of instability. The Veteran had surgical scars, but they were not painful and/or unstable, or of a total area greater than 39 square centimeters (six square inches). He would constantly use a knee brace for assistance. The functional impact on the Veterans employment status was described as difficulty sitting or standing for long periods of time without rest; difficulty going up or down steps or stairs; and difficulty walking uneven surfaces. There was evidence of pain on non-weight-bearing, but passive range of motion testing could not be done safely. The examiner added that for the established diagnosis of traumatic arthritis of the left knee status post multiple meniscectomies, there was a worsening of the Veteran’s symptoms, however no change to the service connected diagnosis and no additional diagnoses had been rendered. As indicated above, the Veteran’s left knee has been rated separately Diagnostic Codes 5259 (symptomatic removal of semilunar cartilage), 5261 (limitation of extension), and 7802 (scar, not of the head, face, or neck). With specific regard to rating for the meniscal symptoms of the left knee, the Board finds that the while the RO rated the disability under Diagnostic Code 5259 for the symptomatic removal of semilunar cartilage, the Veteran’s disability more closely approximates the criteria for rating under Diagnostic Code 5258 which provides the criteria for dislocation of semilunar cartilage. Under Diagnostic Code 5258, a 20 percent disability rating is warranted when there is dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. The VA examiner in December 2019 specifically indicated that there was a history of a meniscus condition that was manifested by frequent episodes of joint locking, joint pain, and joint effusions. The examiner further attributed the residuals to the service-related left knee surgeries conducted in 1989, 1992, 2000, and 2001. As such, the Board finds that he left knee is more appropriately rated under Diagnostic Code 5258 such that a 20 percent disability rating is warranted. Additionally, the Board notes that as the Veteran’s claim for an increased disability rating was received by the RO on September 14, 2012, the separate rating should be effective as of the date of claim. The left knee disability has also been rated separately for limitation of extension under Diagnostic Code 5261, which has been rated at 10 percent prior to December 4, 2019, and at 30 percent thereafter. A review of the medical evidence of record shows that in April 2013, May 2014, and June 2015, extension was full, to zero degrees. In July 2018, extension was limited to four degrees, and in December 2019, it was limited to 20 degrees. In order to meet the criteria for a disability rating higher than the currently assigned 10 percent prior to December 4, 2019, extension would have to be limited to 15 degrees, which has not been demonstrated. Similarly, in order to merit a disability rating greater than 30 percent under Diagnostic Code 5261 from December 4, 2019, extension would have to be limited to 30 degrees which has never been demonstrated. Consideration has been given to assigning a higher disability rating under Diagnostic Code 5260 for limitation of flexion. In this regard, on each examination of record, flexion has never been limited to 45 degrees or less so as to merit a compensable disability rating under this diagnostic code provision. Consideration has been given to assigning a higher disability rating based on functional loss due to pain, weakness, fatigability, and incoordination causing additional disability beyond that reflected on range of motion measurements. However, based on the examination reports summarized above, there was no additional loss of range of motion or functional impairment following repetitive use when such testing was able to be conducted. In reviewing the symptoms and other evidence of record, there is insufficient showing of functional loss supported pathology and objective observation to warrant an increased disability rating for either flexion or extension. Over the entire course of the period on appeal, the Veteran has consistently asserted that he has had to wear a heard knee brace for stability because the left knee would otherwise give way. In April 2013, he described that the knee would lock up and give way at times. In May 2014, he indicated it would periodically lock up and give way. In July 2018, it was indicated that the knee would give way often with the joint giving way to the anterior direction. In December 2019, the examiner specifically indicated that there was a history of moderate lateral instability. Evaluation of a knee disability under DCs 5257 or 5261 or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under DCs 5258 or 5259, and vice versa. Lyles v. Shulkin, 29 Vet. App. 107, 109 (2018). When evaluating disabilities, including musculoskeletal disabilities, the aim of the rating schedule is to ensure that a claimant is properly compensated, but not overcompensated, for the actual level of impairment. To that end, VA regulation prohibits duplicate compensation for the same manifestation of disability under different diagnoses. 38 C.F.R. § 4.14. A veteran cannot be compensated more than once for the same disability. It follows that, where a certain manifestation of a disability has not been compensated via an assigned evaluation under a particular Diagnostic Code, evaluation of that manifestation under another Diagnostic Code would not constitute prohibited pyramiding under 38 C.F.R. § 4.14. A manifestation of disability has not been compensated by an assigned evaluation if the manifestation is distinct and separate from the manifestations that form the basis of the assigned evaluation. Separate knee evaluations may be warranted where the appellant's symptoms are distinct and separate. In this case, the Veteran’s symptom of instability is separate and distinct from his painful motion, and locking with effusion. Accordingly, a separate 20 percent disability rating is warranted since the date of claim for moderate lateral instability of the left knee under Diagnostic Code 5257. While the earlier examinations did not specifically identify the lateral instability, the Veteran’s competent statements, coupled with the evidence of constant use of a knee brace and the December 2019 examiner’s finding of a history of moderate lateral instability, suggest that the criteria have been met since the date of claim (September 14, 2012). The criteria for a higher 30 percent disability rating have not been met as the evidence has not suggested that the left knee has been manifested by severe lateral instability. The Board has considered the Veteran’s knee disability under other potentially applicable diagnostic code provisions. In this regard, the evidence does not show that the Veteran experienced ankylosis of the knee joint, as he was able to demonstrate movement. In addition, there is no evidence that a knee was manifested by an impairment of the tibia or fibula or genu recurvatum. Therefore, Diagnostic Codes 5256, 5262, and 5263 are not for application in this case. Finally, the left knee scars associated with the traumatic arthritis of the left knee, have been separately rated as noncompensable under Diagnostic Code 7802 by the RO, effective as of October 2, 2013. Skin disabilities, to include scars, are rated under 38 C.F.R. § 4.118 that provides the schedule of ratings for the skin. Diagnostic Code 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under diagnostic codes 7800, 7801, 7802, and 7804 under an appropriate diagnostic code. Diagnostic Code 7800 contemplates scars of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800. As the Veteran’s service-connected scars are located on his left lower extremity, a compensable rating is not warranted under Diagnostic Code 7800. Diagnostic Code 7801 provides ratings for burn or other scars (not on the head, face, or neck) that are deep and nonlinear. Deep and nonlinear scars involving an area or areas of at least 6 square inches (39 sq. cm) but less than 12 square inches (77 sq. cm.) are rated 10 percent. Scars in an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) are rated 20 percent. Scars in an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) are rated 30 percent. Scars in an area or areas of 144 square inches (929 sq. cm.) or greater are rated 40 percent. 38 C.F.R. § 4.118. Note (1) specifies that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Note (2) specifies that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under §4.25. Qualifying scars are scars that are nonlinear, superficial, and are not located on the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7801. Diagnostic Code 7802 provides a maximum 10 percent rating for a burn or other scars that are superficial and nonlinear involving an area of 144 square inches (929 sq. cm) or greater. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) specifies that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under §4.25. Qualifying scars are scars that are nonlinear, superficial, and are not located on the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7802. Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful, a 20 percent rating for three or four scars that are unstable or painful, and a 30 percent rating for five or more scars that are unstable of painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804. In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. Under the amended criteria which became effective on August 13, 2018, Diagnostic Codes 7800 and 7804 were not changed. 38 C.F.R. § 4.118. Diagnostic Code 7801 now provides for burn scars of scars due to other causes, not of the head, face, or neck that are associated with underlying soft tissue damage. The rating criteria for this code remained the same. But Note (1) now reads: For the purposes of Diagnostic Codes 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) now reads: A separate evaluation may be assigned for each affected zone of the body. Combine the separate evaluations under §4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. 38 C.F.R. § 4.118. Under the amended criteria which became effective on August 13, 2018, Diagnostic Code 7802 now provides for burn scars or scars due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. The rating criteria remained the same. But Note (1) now reads: For the purposes of Diagnostic Codes 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) now reads: A separate evaluation may be assigned for each affected zone of the body. Combine the separate evaluations under §4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. 38 C.F.R. § 4.118. Diagnostic Code 7805 was amended in that the parentheses which noted that linear scars were included was removed. The title now provides for scars, other and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804. The rating criteria remained the same. 38 C.F.R. § 4.118. The Board finds that the preponderance of the evidence is against a compensable rating for the Veteran’s service-connected surgical scars of the left knee. Under both the prior rating criteria and the amended rating criteria, a compensable rating is not warranted pursuant to Diagnostic Code 7801. The pre-amendment Diagnostic Code for 7801 pertained to deep and nonlinear scars. Here, there is no evidence that the Veteran’s scars cover an area of at least 6 square inches, or that they are deep. Hence, the pre-amendment Diagnostic Code 7801 is not for application. The amended criteria for Diagnostic Code 7801 pertain to scars associated with underlying soft tissue damage. Here there is no evidence that the Veteran’s scars cover an area of at least 6 square inches, or that they are associated with underlying soft tissue damage. Hence, the amended criteria for Diagnostic Code 7801 is similarly not for application. 38 C.F.R. § 4.118. Under both prior rating criteria and the amended rating criteria, a compensable rating is not warranted pursuant to Diagnostic Code 7802. This is so because the Veteran’s scars do not cover a surface area of 144 square inches (929 sq. cm) or greater; therefore, a compensable rating is not available under either the prior Diagnostic Code 7802 which pertains to superficial and nonlinear scars or the amended rating criteria which pertains to scars not associated with soft tissue damage. 38 C.F.R. § 4.118. As noted, Diagnostic Code 7804 was not amended. Diagnostic Code 7804 contemplates scars that are unstable or painful. 38 C.F.R. § 4.118. As noted at the VA examinations discussed above, the Veteran’s scars are not unstable or painful; therefore, a compensable rating is not warranted under Diagnostic Code 7804. 38 C.F.R. § 4.118. Finally, as to both the prior rating criteria and the amended Diagnostic Code 7805, no scar has not been found to result in limitation of function. There have been no other pertinent physical findings, complications, signs and/or symptoms (such as muscle or nerve damage) associated with any scar (regardless of location). In sum, a compensable rating is not warranted at any point during the rating period on appeal for the surgical scars of the left knee. The Board does note, however, that the RO had assigned an effective date of the separate rating as October 2, 2013. This date does not reflect the date of claim for an increased disability rating for the service-connected left knee disability. Rather, the effective date of the establishment of a separate noncompensable disability rating for the service-connected left knee scars associated with the traumatic arthritis of the left knee under Diagnostic Code 7802 is September 14, 2012. REASONS FOR REMAND 1. Entitlement to a TDIU prior to May 31, 2016. In light of the grant of separate service connection for lateral instability of the left knee, coupled with the assignment of increased disability ratings for the PTSD and for the left knee multiple meniscectomies, along with the earlier effective dates assigned above, a remand is necessary in order for the agency of original jurisdiction to implement the allowances prior to consideration of the claim of entitlement to a TDIU prior to May 31, 2016. Therefore, the claim is inextricably intertwined and, before the issue of entitlement to TDIU can be addressed on appeal, the grants of service connection and increased disability ratings must be implemented. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matter is REMANDED for the following action: Following the implementation of the awards of separate service connection for lateral instability of the left knee, coupled with the assignment of increased disability ratings for the PTSD and for the left knee multiple meniscectomies, along with the earlier effective dates assigned above, readjudicate the claim for a TDIU prior to May 31, 2016. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Orfanoudis, 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.