Citation Nr: 21013249 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 15-00 334 DATE: March 9, 2021 ORDER Entitlement to an increased disability evaluation in excess of 30 percent prior to October 16, 2020, and in excess of 60 percent thereafter for residuals of total right-knee replacement, to include an earlier effective than October 16, 2020, for the 60 percent evaluation, is denied. Entitlement to an increased disability evaluation in excess of 50 percent for post-traumatic stress disorder (PTSD), prior to April 19, 2018, is denied. An evaluation of 70 percent, but no higher, is granted as of April 19, 2018. The appeal is allowed to this extent. FINDINGS OF FACT 1. The objective medical evidence shows at no time during the appeal period prior to October 16, 2020, did residuals of total right-knee replacement more closely approximate chronic residuals consisting of severe painful motion or weakness, favorable or unfavorable ankylosis, right-knee extension limited to 30 degrees, any impairment of the tibia and fibula, or scars, not of the head, face or neck, which are deep and nonlinear and in an area or areas of 144 square inches (929 sq. cm.) or greater, nor does the evidence of record present an exceptional or unusual disability picture which would render impractical the application of the schedular evaluation criteria. 2. The objective medical evidence shows in the period prior to April 19, 2018, the Veteran’s PTSD more nearly approximated occupational and social impairment, with reduced reliability and productivity due to associated symptoms. 3. As of April 19, 2018, the PTSD more nearly approximates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to associated symptoms, suggested by or similar to the criteria set forth under the General Rating Formula for Mental Disorders. CONCLUSIONS OF LAW 1. The criteria for an increased disability evaluation in excess of 30 percent prior to October 16, 2020 for residuals of total right-knee replacement and in excess of 60 percent thereafter, to include an earlier effective date than October 16, 2020 for the 60 percent evaluation, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5256, 5261, 5262 (2020). 2. The criteria for an increased disability evaluation in excess of 50 percent prior to April 19, 2018 for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.6, 4.130, Diagnostic Code 9411 (2020). 3. With resolution of reasonable doubt in the Veteran’s favor, as of April 19, 2018, the criteria for an increased evaluation to 70 percent, but no higher, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.6, 4.130, Diagnostic Code 9411 (2020). 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.6, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from January 1993 to May 2002. In February 2018, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. The evaluation of a service-connected disorder requires a review of a veteran’s entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126–27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). 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). Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 1. Entitlement to an increased disability evaluation in excess of 30 percent prior to October 16, 2020 and in excess of 60 percent thereafter for residuals of total right-knee replacement, to include an earlier effective date than October 16, 2020 for the 60 percent evaluation. In the period prior to October 16, 2020, the Veteran’s right-knee disorder was evaluated under Diagnostic Code 7805-5055. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned, appearing after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 7805 is the code used for rating scars and effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804, with disabling effects not considered in those diagnostic codes to be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118 Diagnostic Code 7805. To the extent that the Agency of Original Jurisdiction (AOJ) has used a hyphenated diagnostic code, scars, in effect, are rated under the criteria for limitation due to knee replacement under Diagnostic Code 5055. In its revised version, effective February 7, 2021, Diagnostic Code 5055, provides a 100 percent rating for knee, resurfacing or replacement (prosthesis), for 4 months following implantation of prosthesis or resurfacing. Thereafter, a 60 percent rating is available when, with the prosthetic replacement of the knee joint, there are chronic residuals consisting of severe painful motion or weakness in the affected extremity and, with intermediate degrees of residual weakness, pain or limitation of motion, evaluation will be by analogy to diagnostic codes 5256, 5261 or 5262. A 30 percent rating is warranted as a minimal evaluation for a total replacement only. A Note explains that, at the conclusion of the 100 percent evaluation period, evaluate resurfacing under diagnostic codes 5256 through 5262; there is no minimum evaluation for resurfacing. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Prior to February 2021, the 60 and 30 percent ratings were rated under the same provisions. Only the time period for the 100 percent rating changed, and that is not at issue in this decision. Diagnostic Code 5256 provides a 30 percent rating for ankylosis of a knee at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 50 percent rating is available for ankylosis of a knee between 20 degrees and 45 degrees. A 60 percent rating is warranted for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Under Diagnostic Code 5261, a rating of 30 percent is assigned where extension is limited to 20 degrees while a 40 percent rating is warranted where extension is limited to 30 degrees. A 50 percent is warranted available where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5262, now revised, effective February 7, 2021, addressing impairment of the tibia and fibula, provides a 30 percent rating when there is medial tibial stress syndrome (MTSS), or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. A 40 percent rating is assigned for nonunion of the tibia and fibula, with loose motion, requiring a brace. Malunion would be evaluated under Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Previously, ratings were assigned for malunion or nonunion with consideration of knee or ankle impairment. The VA General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261 may be assigned for limitation of flexion and extension of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). As stated above, as part of the hyphenated diagnostic code under which the Veteran’s total right-knee replacement was evaluated, Diagnostic Code 7805, providing ratings for the scar or scars associated with the Veteran’s total right-knee replacement. The Board will note here briefly that, effective August 13, 2018, VA published a final rule amending its regulations on skin disabilities, to include scars. The amendment added a General Rating Formula for the Skin (General Rating Formula) for certain diagnostic codes, and it amended still others. See 83 Fed. Reg. 32,592 (July 13, 2018). Claims pending prior to the August 13, 2018 effective date will be considered under both old and new rating criteria and whichever criteria is more favorable to the Veteran will be applied. Under the version of Diagnostic Code 7805 when the 30 percent initial rating was assigned for total right-knee replacement in February 2013, scars and effects of scars, other than those evaluated under Diagnostic Codes 7800 – 7804, including linear scars, are to be rated based on any disabling effects under an appropriate diagnostic code for such effects. See 38 C.F.R. § 4.118, Diagnostic Code 7805 (2013). In addition, the effects of scars otherwise rated under Diagnostic Codes 7800 - 7804 are to be considered. 38 C.F.R. § 4.118, Diagnostic Code 7805. However, under the August 2018 amended versions, Diagnostic Code 7805 in fact was not amended and has remained the same as prior to the revision. The Board will address below the applicability of Diagnostic Code 7805 and any relevant diagnostic codes as findings in the record or on examination warrant it. VA regulations also direct that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2020) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2020). DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Additionally, the United States Court of Appeals for Veterans Claims (Court) has held that pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 (2020) but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Turning to the record, the Board notes at the outset that between 1991 and 2011, it appears the Veteran had no less than five arthroscopic procedures and surgeries regarding a right-knee meniscus tear, culminating in a December 2011 total right-knee replacement. The Board also notes that, in the period between January 2005 and March 2012, the Veteran’s right knee was successively rated at 10 percent, then 100 percent for several periods of convalescence after surgeries, to include total right-knee replacement, then reduced to 10 percent again. In a January 2012, the Veteran submitted a claim for rating in excess of 10 percent for right knee. For the purpose of establishing the appeal period for this claim, the Board further notes that a March 2014 rating decision continued the earlier award of a 10 percent rating for right-patellofemoral syndrome with degenerative joint disease (claimed as patellofemoral syndrome bilateral). The Veteran’s Notice of Disagreement (NOD) for this claim followed in May 21, 2014. A November 2014 rating decision then reduced the claim to a noncompensable disability evaluation, effective December 20, 2011. However, the decision also granted service connection for total right-knee replacement with scar, with an evaluation of 100 percent effective December 20, 2011, followed by an evaluation at 30 percent, assigned from February 1, 2013. Therefore, VA’s receipt of the NOD on May 21, 2014 signals the commencement of this appeal period. The Board generally begins its consideration of the evidence of record from one year prior to that date. In April 2013 through January 2014 visits to his VA primary care physician, the Veteran received assessments of chronic right-knee pain after total right-knee replacement. In this period, he exhibited right-knee swelling, reported he could not bend the right knee and further reported pain at 4 to 6/10 on a 1-10 scale. Although the Veteran presented to his private treatment practice, Bayside Orthopaedic Sports Medicine & Rehabilitation Center, with complaints of right-knee pain, the treatment provider found on physical examination, “[r]ight knee today demonstrates no swelling. Excellent alignment, stability, and range of motion. No sign of infection. No sign of DVT [deep-vein thrombosis].” Moreover, x-rays revealed right-knee implants to be intact, without signs of loosening, migration or dislodgement and the components were properly positioned in size. The diagnostic impression was “[o]bjectively excellent appearance right knee replacement.” In a February 2014 VA examination for knee and lower leg conditions, the Veteran was diagnosed with service-connected right patellofemoral syndrome with degenerative joint disease, status post total right-knee replacement. The February 2014 VA examiner noted the Veteran’s reports of less mobility since the surgery, as well as constant pain in the medial knee and pain worse with more movement, kneeling and going up and down ladders. Range of motion findings indicated right-knee flexion at 120 degrees (140 normal), no limitation of motion in extension and no objective evidence of painful motion in either maneuver. The Veteran did not report that flare-ups impacted function, but the VA examiner found diminished motion with repeated use over time. Three right-knee joint stability tests showed normal results. Muscle strength testing showed right-knee normal strength (5/5). The February 2014 VA examiner made single findings of no evidence or history of recurrent patellar subluxation/dislocation and the Veteran did not have or ever had “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The February 2014 VA examiner noted the December 2011 total right-knee replacement and found residuals were intermediate degrees of residual weakness, pain or limitation of motion. In conjunction with his reported difficulties in kneeling, bending and climbing, the February 2014 VA examiner found the Veteran had mild functional limitation and was able to work. She found knee-scars were not painful and/or unstable, nor are they the total area of all related scars greater than 39 square cm (6 square inches). In December 2013 and May 2014 VA orthopedic clinic visits, the treatment providers noted the Veteran’s reports of persistent pain at 4/10 and swelling, but also noted that x-rays showed a well-healed replacement site and examination indicated no warmth, no joint effusions, normal stability for a knee replacement, and no signs of infection or loosening of implants. They further stated motion was “very full to 130 degrees active.” The possibility for an evaluation for revision of the total right-knee replacement was discussed. A November 2014 VA kinesiotherapy note shows active range of motion for flexion of the right knee at 0 – 100 degrees. The Veteran continued to report pain and the inability to bend the right knee through September 2016. During this and previous periods, it was noted the Veteran did not resort to pain medications. April 2017 x-rays showed status post total right knee arthroplasty with the prosthetic components appearing in satisfactory alignment and position. In the November 2017 VA examination for knee and lower leg conditions, the VA examiner gave a left-knee diagnosis, but none for the right knee. Nonetheless, she recorded right-knee range of motion at 0 - 125 degrees for flexion and 125 - 0 degrees for extension. Although finding pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups for left knee, she made no finding for the right knee. The November 2017 VA examiner found right-knee muscle strength to be normal at 5/5, with no muscle atrophy. She found there was no left-knee ankylosis, but made no finding for the right knee. Similarly, she made no findings for right-knee joint stability tests. She made a single finding that the Veteran did not have or ever had had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The November 2017 VA examiner found the Veteran’s regular use of a cane was for both left-knee patellofemoral syndrome and for total right-knee replacement. She further found no x-ray documentation of degenerative or traumatic arthritis. This VA examiner found there in fact were no scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the diagnosis section (in which no diagnosis for right-knee was entered). From the November 2017 VA examination through July 2020, the Veteran continued to present at VA with complaints of chronic right-knee pain in the area of the knee cap. A March 2018 private treatment note shows on cursory examination that the Veteran skin was clean, dry and intact. In April 2019, a VA podiatric note shows the treatment provider, on cursory physical examination, noted the Veteran’s surgical scars at the medial-right knee and right-upper leg and entered his next finding as “[s]kin is supple with good turgor. No open wounds.” Also in April 2019, the Veteran consulted for a possible private treatment pain ablation procedure. The treatment provider also assessed the Veteran with a lateral tracking right-knee patella, indicating his kneecap was not properly aligned and moving sideways. May 2019 private treatment notes at Clearway Pain Solutions noted that the Veteran’s pain has failed to respond to conservative therapy or to surgery therapy, to include a right-total knee replacement, and he would like to proceed with a right-knee genicular nerve block. Prosthetic components appeared in satisfactory alignment. He was assessed with right-knee pain. In June 2019, the Veteran underwent a private procedure for right-knee genicular nerve block. As directed in the Board’s August 2019 Remand, the Veteran was afforded a December 2019 VA examination for knee and lower-leg conditions, in which the VA examiner diagnosed right-popliteal pseudoaneurysm, repaired and right-knee replacement. He noted the Veteran’s reports of flare-ups of the right knee occurring daily, being moderate, but lasting for hours. The right knee flare-ups were precipitated by walking, bending, standing, climbing stairs or ladders and are alleviated by rest, heat and ice. The Veteran further reported functional loss or impairment happens when standing, which is limited to 30 minutes at a time and no walking more than 200 yards at a time. Range of motion measurements show right-knee flexion at 0 to 100 degrees (0 to140 degrees, normal) and extension at 100 to 0 degrees (140 to 0 degrees, normal). There was no evidence of pain with weight-bearing. There was no further loss of range of motion on observed repetitive use. However, the December 2019 VA examiner found pain significantly limited functional ability with repeated use over a period of time. Although he did not examine the Veteran immediately after repeated use over time, the December 2019 VA examiner estimated the loss of range of motion for right-knee flexion at 0 to 95 degrees and extension at 95 to 0 degrees. Additionally, once again, the December 2019 VA examiner found pain significantly limited functional ability during flare-ups. Although the examination was not conducted during a flare-up, the December 2019 VA examiner estimated the loss of range of motion for flexion at 0 to 90 degrees and extension at 90 to 0 degrees. He also found additional contributing factors to right-knee disorder to be instability of station. However, regarding weakness, muscle strength testing showed right-knee muscle strength at normal strength (5/5), nor was there right-knee muscle atrophy. The December 2019 VA examiner further found no right-side ankylosis, no history of recurrent right-knee subluxation and only a history of “slight” lateral instability. Additionally, 4 joint stability tests for the right knee each produced normal findings. The December 2019 VA examiner found the Veteran did not have or ever had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He further found the Veteran regularly uses a right-knee brace. He noted there were no available imaging studies to document degenerative or traumatic arthritis. The October 2020 VA examiner found the Veteran does have scars related to his disorder, but none of them is painful or unstable; they do not have a total area equal to or greater than 39 square cm (6 square inches); or are located on the head, face or neck. He found three scars on the right knee, measuring 22 cm in length and a width of 0.2 cm. He further noted the Veteran’s December 2011 total right-knee replacement and found its residuals to be intermediate degrees of residual weakness, pain or limitation of motion. In looking to the findings of the February 2014 and November 2017 VA examinations, the Board first notes again that Diagnostic Code 5055 provides a 60 percent rating when, with the prosthetic replacement of the knee joint, there are chronic residuals consisting of severe painful motion or weakness in the affected extremity and, with intermediate degrees of residual weakness, pain or limitation of motion, evaluation will be by analogy to diagnostic codes 5256, 5261 or 5262. However, although the Veteran reported at the February 2014 VA examination constant right-knee pain, he further reported he was taking no medications for pain, suggesting, as a factual determination, that his pain was not severe. Moreover, in range of motion testing, the February 2014 VA examiner found there was no objective evidence of painful motion. In the November 2017 VA examination, as stated above, although there were findings for left-knee pain during range-of-motion testing, the November 2017 VA examiner made no findings for the right knee. In regard to findings of weakness, the February 2014 and November 2017 VA examiners both found muscle strength testing showed right-knee normal strength (5/5), nor was there right-knee muscle atrophy. There were no findings in either examination of weakness significantly limiting functional ability. Neither examination therefore provides findings for a rating at 60 percent under Diagnostic Code 5055. The February 2014 VA examiner also found at the end of the examination residuals of the December 2011 total right-knee replacement to be “intermediate degrees” of residual weakness, pain or limitation of motion. As stated above, under Diagnostic Code 5055, higher ratings may also be assigned when there are intermediate degrees of residual weakness, pain or limitation of motion, as rated by analogy under Diagnostic Codes 5256, 5261 or 5262. Looking first to Diagnostic Code 5256, as set forth above, a 40 percent rating may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 50 percent rating may be assigned for ankylosis of a knee between 20 degrees and 45 degrees. A 60 percent rating may be assigned for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. However, the February 2014 VA examiner made no findings regarding ankylosis and the November 2017 VA examiner, although specifically finding there was no left-knee ankylosis, made no finding for right knee. Without any finding of ankylosis no higher rating is available under this diagnostic code. Under Diagnostic Code 5261, a 40 percent rating is warranted where extension is limited to 30 degrees and a 50 percent is warranted where extension is limited to 45 degrees. However, the most limited range of motion for right-knee extension found in either the February 2014 VA examination or the November 2017 VA examination was 125 to 0 degrees. Diagnostic Code 5262 allows for a 40 percent rating for nonunion of the tibia and fibula, with loose motion, requiring a brace and malunion would be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Both VA examiners made a specific single finding of the Veteran not having or ever having had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. Therefore, this diagnostic code can offer no higher rating. Additionally, only the February 2014 VA examiner noted the Veteran’s right-knee scars, but found they were not painful and/or unstable, nor was the total area of all related scars greater than 39 square cm (6 square inches). The Board, as directed by Diagnostic Code 7805 for scars, also has considered the applicability of other potentially applicable diagnostic criteria in the range of Diagnostic Codes 7800 - 7804, but finds the only relevant related diagnostic code is 7801, which in both the pre-August 2018 version and the August 2018 amended version allows a rating beyond the 30 percent already assigned to the Veteran. It provides a 40 percent rating for burn scars or scars due to other causes, not of the head, face or neck, that are deep and nonlinear, in an area or areas of 144 square inches (929 sq. cm.) or greater. A “deep” scar is one associated with underlying soft tissue damage. However, as shown above, there is no finding in the February 2014 VA examination of a “deep” scar, as there were no findings of underlying soft tissue damage and they do not cover the area in square centimeters/inches specified above. The Board notes at the this point that, in response to the October 2020 Supplemental Statement of the Case (SSOC), the Veteran’s representative submitted a November 2020 Brief, in which he asserts Veteran is entitled to a 60 percent disability compensation rating for his service-connected residuals of a right-knee replacement, effective December 2, 2019. Specifically, he contends that the earlier findings in the December 2019 VA examination had already satisfied the criteria for the 60 percent rating, awarded on the basis of the findings in the October 2020 VA examination. He asserts that the December 2019 VA examiner opined that that the Veteran suffers from flare-ups in the right knee on a daily basis that last for hours and that the VA examiner noted flare-ups are precipitated by walking, standing, climbing stairs or ladders and the Veteran suffers from functional loss on use of the affected extremity, being limited to standing for 30 minutes at a time and only walking 200 yards at a time at most. The Veteran’s representative makes reference to the examination findings for pain significantly limiting functional ability during repeated use over time and during flare-ups, as set forth above. He adds that the October 2020 SSOC committed reversible error in not addressing these findings. It is on this basis that he asserts that the Veteran therefore met the requirements for a 60-percent rating on December 2, 2019, the date of the VA examination, rather than the date of the subsequent VA examination in October 2020. Once again turning to Diagnostic Code 5055, based on the Veteran’s own reports that day, the December 2019 VA examiner noted the Veteran’s flare-ups were at a moderate level of pain, not severe. There are no further reports by the Veteran or findings by the VA examiner describing the level of intensity of pain. In regard to findings of weakness, the December 2019 VA examiner found muscle strength testing showed right-knee muscle strength at normal strength (5/5), nor was there right-knee muscle atrophy. Moreover, there were no findings that weakness significantly limited function ability during repeated use over time and flare-ups, only pain. The December 2019 VA examination therefore does not provide findings for a rating at 60 percent under Diagnostic Code 5055. However, the December 2019 VA examiner also found at the end of the examination residuals of the December 2011 total right-knee replacement to be “intermediate degrees” of residual weakness, pain or limitation of motion and, once again, under Diagnostic Code 5055, higher ratings may also be assigned when there are intermediate degrees of residual weakness, pain, or limitation of motion, by rating by analogy to Diagnostic Codes 5256, 5261 or 5262. Looking again to Diagnostic Code 5256, it provides 40, 50 and 60 percent ratings for findings some form of ankylosis, with limitations of flexion ranging from 10 to 45 degrees. However, the December 2019 VA examiner made found no ankylosis whatsoever. Without a finding of ankylosis, no higher rating is available under this diagnostic code. Under Diagnostic Code 5261, 40 and 50 percent ratings are is warranted when extension is limited from 30 to 45 degrees. However, the December 2019 VA examiner found limited range of motion for right-knee extension 100 to 0 degrees. Diagnostic Code 5262 allows for a 40 percent rating for nonunion of the tibia and fibula, with loose motion, requiring a brace and malunion would be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. The December 2019 VA examiner found the Veteran did not have or ever had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. Therefore, this diagnostic code can offer no higher rating. For the same reasons stated above, Diagnostic Code 7801 provides no higher rating, as the Veteran’s scars are not deep or of the size required. The November 2020 Brief’s last argument is that the Veteran’s symptomatology met the criteria for severity and therefore a 60 percent rating, under Diagnostic Code 5055 on December 2, 2019, the date of the December 2019 VA examination, rather than the date of the subsequent VA examination in October 2020. The effective date for an increased evaluation for a service-connected disorder is also generally the date the claim was received or when entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (o)(1). However, compensation can also be awarded up to one year before the date of claim, provided the claim for an increased disability rating was received within one year of the increase in disability, as shown by the evidence. That is to say, the effective date of such an increase would then be the date the increase was “factually ascertainable.” If the increase occurred more than one year prior to the claim, the increase is effective on the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110 (a) and (b)(2); 38 C.F.R. § 3.400 (o)(1)(2). See also Dalton v. Nicholson, 21 Vet. App. 23, 31-32 (2007); Harper v. Brown, 10 Vet. App. 125 (1997). The Brief asserts that the December 2, 2019 is the date entitlement arose for a 60 percent rating. The Board does not agree. As indicated in the above discussion of the findings in the December 2019 VA examination and their relation to the numerous and varied criteria of Diagnostic Code 5055 and the related or analogous diagnostic codes, the relevant findings simply were not made on examination. Moreover, the record in the period near to the December 2019 VA examination als does not support an earlier effective date. For example, although a private treatment provider in April 2019 assessed the Veteran with a right kneecap moving sideways (lateral tracking), as a factual determination to be made by the Board, a finding of a floating kneecap does not give indication of severe pain, weakness, limited extension, ankylosis, or a tibial or fibular impairment. Therefore, for the same reasons already discussed, no higher evaluation is available under the relevant diagnostic codes. In view of these findings, December 2, 2019 cannot be assigned as the effective date for a 60 percent rating, as no findings support the necessary criteria for that evaluation. In October 2020, the Veteran underwent his most recent VA examination for knee and lower-leg conditions, in which the VA examiner stated the December 2011 diagnosis of status post total right-knee replacement. He noted the Veteran’s reports of flare-ups of the right knee occurring daily, being severe and lasting all day. The right knee flare-ups are precipitated by standing, walking and bending and are alleviated by rest. The Veteran further reported functional loss or impairment, with pain, stiffness, decreased range of motion, difficulty with prolong walking, and standing. Range of motion measurements show right-knee flexion at 0 to 75 degrees (140 degrees, normal) and extension at 75 to 0 degrees (140 to 0 degrees, normal). In this examination, there was evidence of pain with weight-bearing. There was further loss of range of motion on observed repetitive use, resulting in flexion at 0 to 65 degrees and extension at 65 to 0 degrees. The October 2020 VA examiner found both pain and weakness significantly limited functional ability with repeated use over a period of time. Although not examined immediately after repeated use over time, he estimated the loss of range of motion for right-knee flexion at 0 to 55 degrees and extension at 55 to 0 degrees. Once again, the October 2020 VA examiner found pain and weakness significantly limited functional ability during flare-ups. Although the examination was not conducted during a flare-up, the October 2020 VA examiner estimated the loss of range of motion for flexion at 0 to 45 degrees and extension at 45 to 0 degrees. He also found additional contributing factors to right-knee disorder to be instability of station. However, regarding weakness, muscle strength testing showed right-knee muscle strength at normal strength (5/5), nor was there right-knee muscle atrophy. He further found no right-side ankylosis, no history of recurrent right-knee subluxation and, as found in the December 2019 VA examination, only a history of “slight” lateral instability. Additionally, 4 joint stability tests for the right knee each produced normal findings. The October 2020 VA examiner found the Veteran did not have or ever had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He found the Veteran regularly uses a right-knee brace. He noted there were no available imaging studies to document degenerative or traumatic arthritis. As the Veteran’s total right-knee replacement is rated solely under Diagnostic Code 5055 as of October 16, 2020, the date of this examination, the Board need not consider any findings on examination regarding right-knee scars. The October 2020 VA examiner further noted the Veteran’s December 2011 total right-knee replacement and found its residuals to be intermediate degrees of residual weakness, pain or limitation of motion and therefore the related or analogous Diagnostic Codes 5256, 5261 and 5262 may be applicable. However, as the Veteran is rated as of the date of this examination at 60 percent, Diagnostic Codes 5256, 5262 and 5262 have no higher ratings to offer. The record offers no further medical evidence in the period following the October 2020 VA examination in support of a higher disability evaluation. The October 2020 rating decision increased the rating to 60 percent, due to post-prosthesis placement with chronic residuals of severe painful motion and, regardless of a finding on examination only of right-knee “lack of endurance,” but not “weakness, post-prosthesis placement with chronic residuals of severe weakness. The Board notes that each of the examinations discussed above otherwise contains appropriate findings relating to any functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination and are accounted for in the schedular evaluation assigned. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). So, too, normal working movements of the body, such as excursion, strength, speed, coordination, and endurance, and inhibited by pain appear in examination findings, are in turn reflected in the disability evaluation. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). See also 38 C.F.R. §§ 4.40, 4.45. Therefore, no higher ratings than those assigned are warranted. Extraschedular Consideration In the February 2018 Board hearing, the Veteran’s representative stated, although the February 2014 VA examiner noted the Veteran’s reports of functional limitation due to his right-knee symptoms of difficulty kneeling, bending and climbing ladders and stools, the November 2017 VA examiner noted the Veteran was now moved off the shop floor for aircraft maintenance for safety reasons since 2016, due to pain and instability and assigned sedentary work. From this, the Veteran’s representative “wanted to note a different, that may be somewhat extra-schedular, between a 2014 and 2017 C&P for [the Veteran’s] right knee that’s service connected [sic]…. So, I know that doesn’t necessarily fall into a diagnostic code, but I certainly think it’s a marked difference between he is working but he was still working on the shop floor [and]… he can’t be on the floor at all, he’s got to be at a desk job,” from which the Board understands the representative to assert that being moved off the shop floor for safety reasons is evidence of pronounced worsening of symptoms not accounted for in the schedular criteria under the relevant diagnostic codes in the period from February 1, 2014 through November 28, 2017, the dates of the examinations, and the claim therefore warrants referral by the Board to the Director of Compensation Service for extraschedular consideration. Consideration for an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and the symptomatology shown and is therefore found to be inadequate, then the second inquiry is whether an exceptional or unusual disability picture emerges, exhibiting other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). In short, the first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran’s disability picture satisfies the requirements of the second inquiry, then the third step is to refer the case to the Director of Compensation Service to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. See also 38 C.F.R. § 321 (b)(1). However, although neither the AOJ nor the Board is permitted to assign an extraschedular rating in the first instance, the Board may review the later determinations of the Director. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996). See also Anderson v. Shinseki, 22 Vet. App. 423, 427. From the record, the Board first notes that the Veteran’s essential contentions throughout his testimony and his reports to treatment providers and examiners are of ongoing, acute right-knee pain and limitations of movement. However, particularly in the period between 2014 through 2017, the February 2014 VA examiner noted the Veteran’s reports of less mobility since the surgery, as well as constant pain in the medial knee and pain worse with more movement, kneeling and going up and down ladders. Yet, the February 2014 VA examiner found right-knee flexion at 120 degrees (140 normal), there was no limitation of motion in extension and no objective evidence of painful motion in either maneuver. Additionally, in December 2013 and May 2014 VA orthopedic clinic visits, the treatment providers noted the Veteran’s reports of persistent pain at 4/10 and swelling, but also noted that x-rays showed a well-healed right-knee and examination indicated no warmth, no joint effusions, normal stability for a knee replacement, and no signs of infection or loosening of implants. The treatment provider further remarked that motion was “very full to 130 degrees active.” A November 2014 VA kinesiotherapy note shows active range of motion for flexion of the right knee at 0 – 100 degrees. The Veteran continued to report pain and the inability to bend the right knee through September 2016. By the November 2017 VA examination, right-knee flexion and extension were back up to 0 - 125 degrees and 125 - 0 degrees, respectively. The foregoing findings show first worsening of symptoms by 20 degrees, but then improvement by 25 degrees. As a factual determination by the Board, this hardly suggests a pronounced worsening of symptoms. Significantly, during this entire period, it was noted the Veteran did not resort to pain medications. Additionally, the Board notes the medical evidence is consistent and unequivocal as to the extent of the Veteran’s limitation of movement and, as discussed at length above, under the criteria of the relevant diagnostic codes, there was no higher evaluation available to the Veteran. Moreover, as the pain attendant on movement is factored into the disability evaluations overall. The Board does not discern in the record evidence of an exceptional or unusual disability picture. The contention by the Veteran’s representative is that from having difficulties in kneeling, bending and climbing, as reported in 2014, to being reassigned from the shop floor maintenance tasks to sedentary work for safety reasons does not just indicate a worsening of symptoms, but an extreme decline so out of the ordinary as to fall beyond anything contemplated in the schedular ratings. This is not readily apparent to the Board from its review of the medical evidence of record. It suggests worsening symptoms at a certain point, but not an extraordinary development in symptomatology. The testing results on examination, both in the February 2014 and November 2017 VA examinations, but also in the December 2019 VA examination, do not support such a conclusion. The Veteran was originally assigned a 30 percent from February 2013 after receiving a total rating for total right-knee replacement and its period of convalescence. The 30 percent rating was then increased to 50 percent, made effective on the same date, thereby accounting the worsening symptoms in evidence in the record. The various test results in 3 VA examinations from 2014 to 2019 did not produce findings to satisfy the schedular criteria for a higher rating in the period prior to October 16, 2020. For these reasons, the Board has no basis to conclude other than pain as a symptom, as well as limited movement, therefore have been accounted for in the rating assigned to the Veteran in this period. While the Board is sympathetic to the Veteran’s challenges, particularly what appears to be incessant pain, based on the totality of evidence, the Board finds the evidence of record does not present an exceptional or unusual disability picture which would render impractical the application of the schedular evaluation criteria and referral of the claim for an increased disability evaluation to the Director of Compensation Service for extraschedular consideration therefore is not warranted. In carefully considering the Veteran’s February 2018 Board hearing testimony, as well as the January 2019 lay statement of his wife, giving details of the Veteran current right-knee symptoms, the Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran and his wife are competent to provide statements of symptoms which are observable to their senses and there is no reason to doubt their credibility. However, the lay evidence of the Veteran and his wife must in turn be weighed against other evidence, as all relevant evidence of varying kinds must be considered. Although the Veteran testified in great detail as to right-knee instability, in the February 2014, December 2019 and October 2020 VA examinations, each VA examiner specifically found normal results in each in a series of 4 joint stability tests of the right knee. The November 2017 VA examiner, although making no specific finding for the right knee, nonetheless did not make any affirmative finding for knee instability during the examination. The examiners’ findings represent an undeniable consistency in medical findings on examination between 2014 and 2020. The Board therefore assigns more probative value to the 4 examination reports in the period, as they were conducted by medical professionals after in-person examination and testing of the Veteran’s right knee, the examiners reviewed of the Veteran’s medical history and their orthopedic findings, for the reasons stated above, exhibit sound clinical conclusions. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). Based on the foregoing reasons and the objective medical evidence, the Board finds the preponderance of the evidence is against an increased rating in excess of 30 percent prior to October 16, 2020 and in excess of 60 percent thereafter, and against an earlier effective date of December 2, 2019 for the 60 percent evaluation. 2. Entitlement to an increased disability evaluation in excess of 50 percent for PTSD. An October 2012 rating decision initially granted the Veteran’s claim for service connection for PTSD at a 30 percent disability evaluation. On August 19, 2013, VA received the Veteran’s claim for an evaluation in excess of 30 percent, thus commencing the appeal period. The Board in its July 2018 decision awarded an initial evaluation at 50 percent, later made effective September 19, 2011. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (the Court), which in its June 2020 memorandum decision found, as the Board did not conduct a proper analysis of the Veteran’s panic episodes, chronic sleep impairment, impaired impulse control, and impairment of work and family relationships, the Board did not address that this contradicted the finding of frequent panic attacks by the Veteran’s private treatment provider and the Board did not provide any further analysis of the evidence of record or discussion as to why a higher rating was not warranted. The Veteran’s psychiatric disorder is currently evaluated under Diagnostic Code 9411, but most psychiatric disorders, including major depressive disorder and anxiety, are evaluated under the General Rating Formula for Mental Disorders (General Rating Formula), which provides a 50 percent evaluation requires demonstrated evidence of occupational and social impairment, with reduced reliability and productivity due to such symptoms as: a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating will be assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, or their effects, that would justify a rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that the claimant’s psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating, then that rating will be assigned. Mauerhan, 16 Vet. App. at 443. Because some of the Veteran’s earlier treatment notes in the period relevant to this appeal assign a Global Assessment of Function (GAF) score under the American Psychiatric Association’s DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th Edition (DSM – IV), it is important to note that the GAF score is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the DSM-IV). A score of 31 to 40 is assigned where there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; a child frequently beats up younger children, is defiant at home, and is failing at school). A score of 41-50 is assigned where there are 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 score of 51-60 is assigned where there are 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, conflict with peers or coworkers). A score of 61-70 is indicated where there are 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 and has some meaningful interpersonal relations. As stated above, the Veteran is currently rated a 50 percent, effective September 9, 2011. The appeal period began on August 19, 2013, with VA’s receipt of the Veteran claim for a higher initial evaluation and the Board will begin its consideration of the evidence in the period of one year prior to that date. Turning to the record, the record shows through the period of at least 2012 to 2020, the Veteran regularly attended mental health appointments at VA for PTSD and was prescribed various medications. Prior to service connection, the Veteran had been treated at VA for irritability and poor sleep. In July 2012, the Veteran reported memories of deployment to Bosnia which “bothered” him. He was diagnosed with insomnia noise nightmares, R/O (rule out) PTSD and assigned a GAF score of 58, indicating moderate symptoms. VA psychotherapy notes in July 2012 and before that date contain the following findings: Grooming/hygiene good. Speech and thought processes/content within normal limits. Appropriate eye contact. Alert, oriented, cooperative. Mood: Variously “tired,” “restless,” “irritable,” “hard to relax.” Affect appropriately reactive and variable; also, somewhat anxious. Denied homicidal ideation/suicidal ideation. The treatment provider noted the Veteran’s reports of noise sensitivity and trouble staying asleep. She assessed the Veteran as: “Experiencing mild to moderate level of emotional distress at this time. He endorses hypervigilance, but also a lot of generalized anxiety symptoms, on edge, trouble relaxing, worrying, restlessness, irritability. Strongly denies suicidal ideation. He is not judged to be in danger of harm to self.” In July 2012, the treatment provider noted: “The Veteran produced a score of 17 on the Beck Depression Inventory (BDI-II), which is suggestive of a mild level of symptomatology (somewhat decreased from April 2012 BDI-II score of 23). He produced a score of 44 on the PTSD Checklist (PCL-C), which is below cutoff, suggestive of significant symptomatology (this is decreased from a April 2012 PCL-C score of 62).” The treatment provider gave diagnoses of PTSD, Depressive Disorder, Dyssomnia (R/O generalized anxiety disorder) and assigned a GAF score of 58, indicating moderate symptoms. August 2012 VA mental status examination results showed the following: General Appearance: neat. Cooperation: good. Mood: anxious. Affect: dysthymic. Speech: normal. Level of Consciousness: alert. Orientation: oriented to person, place and time. Memory: fair. Attention and Concentration: fair. Insight: fair. General Intelligence: fair. Thought Content: Denies auditory hallucinations, visual hallucinations or delusion. Thought Process: fair. Production of Thought: fair. Continuity of Thought: fair. Between December 2012 and February 2013, VA psychiatric outpatient notes state a diagnosis of “PTSD stemming from combat experiences in Bosnia,” with the treatment provider noting the Veteran’s account of the details. He further noted that the Veteran has not been hospitalized or attempted suicide and has been prescribed a series of past medications. The Veteran’s Patient Health Questionnaire (PHQ-9) (9 questions regarding sleep, feeling depressed, self-worth, etc.) showed a score of 18. The interpretive standard states, if greater than 15, it is indicative of severe depression disorder. Scores for the PCL-M (the PTSD checklist for military members) reached 65, indicating PTSD. The Panic Disorder Questionnaire showed four affirmative answers out of 13 questions, with the Veteran’s report of 30-45-minute duration of symptoms and occurring once or less a week. The Veteran was assessed with PTSD and assigned a GAF score of 55, indicating moderate symptoms. February 2013 through October 2014 mental status examinations at VA showed the following: Appearance: neat/well-groomed. Oriented to person, place, time, and situation. Mildly anxious, interactive, responsive. Good eye contact. Speech: Regular rate/rhythm and volume. Mood: “Okay.” Affect: Mildly anxious. Thought Content: No suicidal ideation; no homicidal ideation, no audio/visual hallucinations; and no delusions. Thought Process: Linear. Insight: Fair. Judgment: Fair. Cognition: Long and short-term memory appear to be intact. The Veteran was assessed with PTSD and assigned a GAF score of 55, indicating moderate symptoms. In February 2014, the Veteran underwent a VA examination for PTSD, in which the VA examiner found symptoms of depressed mood, anxiety and chronic sleep impairment. His behavioral observations included the Veteran was casually dressed, with good hygiene and he maintained good eye contact and appeared to be alert, cooperative and well oriented. The February 2014 VA examiner found the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. From August 2012 through December 2013, the Veteran attended veterans group sessions with E.M.W., a Licensed Marriage and Family Therapist, in which PTSD issues were regularly addressed and coping strategies explored. In her August 2013 and June 2014 statements, E.M.W. summarized the Veteran’s combat experiences in Bosnia, as reported by the Veteran, as including stressors of exchanges of gunfire and the suicide and aftermath of a member of the Veteran’s unit. She identified in the Veteran’s behavior avoidance of reminders of combat, including loud noises, crowds, certain movies, and certain smells; hypervigilance in public settings and with persons behind him; memory problems; anxiety with physical manifestations, such as shortness of breath, rapid heart rate and shaking hands; easily angered, with outburst toward others; problems maintaining close relationships with his wife and estranged daughter; the lack of friends; lack of enjoyment; and failure to react accordingly to certain extreme situations. Based on the foregoing, E.M.W. concluded that the Veteran meets the DSM-IV criteria for a diagnosis of PTSD and his symptoms restrict his social and emotion functioning. In April 2018, a private treatment psychiatrist, Dr. J.G.L, evaluated the Veteran in a medical statement drawing his findings made both on a PTSD Disability Benefits Questionnaire (DBQ) and his March 2018 interview with the Veteran. He noted the following: The Veteran was alert and oriented to time, place, and person. Speech was understandable and coherent. Behavior was appropriate to the situation. Mood was depressed, with appropriate affect. Hallucinations and delusions were denied. He readily admitted to feelings of disappointment, anger, fear, anxiety, frustration, tension, and depression in the past week. He has difficulty staying asleep through the night. He said he was exposed to a trauma while serving in Bosnia and has suffered a variety of problems since that event. Dr. J.G.L. also found the following: The Veteran could write a short sentence, read a short sentence and follow the command. When asked to remember three words and immediately repeat them to the examiner, he got all three correct. When asked to do this again after a short delay and interference task, he could remember only one of the original three words. Long-term memory seemed grossly intact, at least in terms of autobiographical information such as date of birth, occupational history, etc. He was not able to carry out successfully serial-7 subtraction from 100. He could remember only six numbers forward and five in reverse. The Veteran reported experiencing significant traumatic events while in the Navy, re-experiencing them with psychological and physical distress, avoidance of activities which trigger those painful memories, and suffering from autonomic arousal which affects his relationships and ability to enjoy restorative sleep. This affects his daily vocational and social activities and causes significant distress. Other symptoms include depressed mood; loss of interest in usually enjoyable activities; diminished energy, easily fatigued; problems concentrating; difficulty remembering simple things; and a sense of hopelessness. He denied any suicidal intention. Dr. J.G.L.’s formal clinical assessment consisted of applying diagnostic tools, such as the Personal Problems Checklist for Adults, during which the Veteran endorsed items indicating social interaction problems, such as not getting along with other people, being uncomfortable in social settings, acting rude and overbearing, being suspicious of others, and feeling out of place in class-type situations. His emotional concerns included being anxious and “uptight,” being tired and having no energy, trouble concentrating, not remembering things, getting to upset and emotional, worries about having a “nervous breakdown,” and not being able to relax and stop worrying. Work-related problems included disliking his supervisor job, disliking fellow employees, being disliked by co-workers, fear of falling on the job, being afraid of losing his job, and having arguments on the job. Family-related problems include disagreements with spouse over how to raise children, spouse alcohol problem, constant arguments with wife, not being understood by his wife, and wife being careless with/wasting money. The Veteran’s responses on the Beck Depression Inventory included constant sadness or unhappiness, nothing to look forward to, seeing his past life as a failure, feelings of unworthiness, and the inability to make decisions. Dr. J.G.L. concluded that the Veteran’s overall score falls in the range usually seen for chronic major depressive disorder; he suffers from persistent, exaggerated negative beliefs about himself and others that are self-defeating and a component of PTSD; and he also has a persistent inability to experience positive emotions, despite being on medication and receiving therapy at VA. Dr. J.G.L. further concluded that the Veteran’s scores on the Post Traumatic Checklist-5 were in the range usually seen in ex-military personnel diagnosed with chronic PTSD, noting that the Veteran has: Repeated disturbing thoughts, memories, images of military trauma; periods when he suddenly feels the trauma is recurring; unpleasant physiological arousal when reminded of the trauma (sweating, etc.); tries to avoid memories or anything that reminds him of the trauma; loss of interest in formerly enjoyable pursuits; a sense of a foreshortened future; emotional numbing and feeling isolated from others; problems with memory and concentration; angry outbursts toward loved ones, constant irritability; and easily startled, always vigilant and on guard for threats. From the foregoing findings, Dr. J.G.L. stated his diagnostic impression based on the criteria of DSM – 5 (5th Edition) as: Post-Traumatic Stress Disorder, Chronic due to military trauma; Major Depressive Disorder, without psychosis, moderate, secondary to chronic PTSD; and Panic Disorder. Psychosocial Stressors include Bosnia deployment, chronic medical problems, financial, and family conflict. Current GAF score using DSM – IV criteria is 40 (indicating some impairment in reality testing or communication or major impairment in several areas). Dr. J.G.L. added the following observations: It is more likely than not that the Veteran has suffered from PTSD with secondary major depressive disorder since service in Bosnia. Based on VA GAP ratings he has had “serious” symptoms since rated at a GAF score of 50 in October 2013 by a VA treatment provider. His current condition based on his chronic PTSD is indicative of major impairment in work and family relations. “I would rate him currently at 40 on the GAF ratings scale. Over time the Veteran’s mental condition has deteriorated.” In Dr. J.G.L.’s April 2018 DBQ, he stated his diagnoses as set forth above in his medical statement. Additionally, he found symptoms of depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; panic attacks more than once a week, chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Dr. J.G.L. stated the Veteran had occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. Between March 2018 and July 2020, VA psychiatry and mental health notes contain mental status examination findings showing the Veteran was interactive and responsive, with good eye contact, speech at a regular rate and rhythm and volume; earlier in the period mood was “stressed” and his affect was anxious, then his mood was euthymic and affect congruent to that and at the end of the period “stressed” and anxious again; his thought content exhibited no homicidal ideation, no suicidal ideation and noted with devotion to his family, no audio/visual hallucinations, and no delusions; his thought process was linear; insight and judgment were fair; and short-term and long-term memory appeared intact. As already stated above, the symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, of their effects or of an occupational and social impairment equivalent which would justify a higher rating. Therefore, the Board will consider when necessary whether some symptoms may be reasonably similar or analogous to the criteria associated with the higher ratings of the General Rating Formula. However, in looking to 38 C.F.R. § 4.126 (a), the Board notes that it “shall consider frequency, severity, and duration of psychiatric symptoms….” The Board understands that regulation, in its use of the phrase “shall consider,” to require consideration of such factors. See also Vasquez-Claudio v. Shinseki, 713 F.3d 112 116-17 (“Reading §§ 4.126 and 4.130 together, it is evident that the “frequency, severity, and duration” of a veteran’s symptoms must play an important role in determining his disability level”) (Fed. Cir. 2013). Consequently, in following this directive, the Board will consider the factual context regarding symptoms, that is to say, by their temporal significance and their intensity. Looking to the period on appeal prior to the April 2018 psychiatric evaluation and DBQ conducted by Dr. J.G.L., the record offers no evidence of treatment and examination with findings to warrant a rating higher than 50 percent. The record does not show reports or findings of impaired thought processes, diminished communication abilities, panic attacks, irritability culminating in violence, or suicidal or homicide ideation. There is no basis on which to assign a higher disability evaluation suggested by rating criteria which are not reasonably applicable to the reports and findings in treatment and on examination. As shown above in VA psychiatric outpatient notes between December 2012 and February 2013, the results of the Panic Disorder Questionnaire showed 4 affirmative answers out of 13 questions, with the Veteran’s report of 30-45-minute duration of symptoms and occurring once or less a week. The Veteran was assessed with PTSD and assigned a GAF score of 55, indicating moderate symptoms. As it is, the criteria under the General Rating Formula for the Veteran’s current assigment of 50 percent in fact suggest panic attacks more than once a week and for 70 percent, “near-continuous panic.” Moreover, a 70 percent rating bespeaks symptoms suggestive of or similar to suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant 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. However, although in the period prior to the J.G.L.’s April 2018 psychiatric evaluation and DBQ, the Veteran reported irritability and did so quite specifically in his February 2018 Board hearing testimony, he did not report or give indication of irritability culminating in violence. His speech patterns were consistently noted in mental status examinations as normal, with regular rate/rhythm and volume, his thought processes were linear and normal and there were no reports of suicidal ideation. Additionally, there we no symptoms suggestive of or similar to irrational thought content, impaired communication, persistent delusions or hallucination, grossly inappropriate behavior, or persistent danger of hurting self or others, as a basis for a total disability rating under the General Rating Formula, discussed more thoroughly below. Therefore, in considering the summary of the record up to Dr. J.G.L.’s April 2018 psychiatric evaluation and DBQ, the preponderance of the evidence supports a finding of occupational and social impairment, with reduced reliability and productivity due to associated symptoms, rated at 50 percent. However, in looking particularly to those symptoms found during treatment or on examination in the latter part of the appeal period, such symptoms specifically include panic attacks that occur weekly or less often, as well as panic attacks more than once a week, as shown in the April 2018 private DBQ, conducted by Dr. J.G.L. These findings support a finding by the Board of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to associated symptoms. As already set forth above, relevant criteria for a 100 percent rating in the General Rating Formula include 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. These are symptoms of total disability, effectively precluding independent functioning. However, although Dr. J.G.L. found symptoms of impaired memory, difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, the considerably more severe symptoms of total occupational and social impairment, suggested by or similar to criteria such as “gross impairment” in thought processes, communication and behavior, as well as disorientation and persistent delusions or hallucinations, are simply not present in the record. Additionally, although Dr. J.G.L. included in his April 2018 findings GAF scores of 40, indicating some impairment in reality testing or communication or major impairment in several areas, the use of GAF scores are not considered in conjunction with diagnoses conforming with DSM – 5. VA, as matter of law, can recognize only such diagnoses and the Board therefore cannot consider GAF scores after the advent of DSM – 5 in 2013. Moreover, Dr. J.G.L. did not make the specific findings of what is indicated by a GAF score of 40. In short, the evidence of record for the appeal period from April 2018 does not show reports by the Veteran or findings on examination of impaired thought processes, diminished communication abilities or suicidal or homicide ideation. There is no basis on which to assign a total disability evaluation suggested by rating criteria which are not reasonably applicable to the reports and findings during treatment and on examination. Once again, the Board has looked to the Veteran’s February 2018 Board hearing testimony, as well as the several lay statements of the Veteran and his wife submitted during the appeal period, and considered them all carefully. As already stated, the Veteran and his wife are competent to provide statements of symptoms which are observable to their senses and there is no reason to doubt their credibility, but the Board must weigh it against other evidence. As such, the record offers detailed accounts of the Veteran’s reports and probing mental status examinations in the period of 2012 through 2020, to which the Board ascribes greater probative value because of their detail and depth. The treatment providers and examiners exhibited close familiarity with the Veteran’s psychiatric history and record of treatment and their conclusions indicate strong clinical grounding. Therefore, in considering the extensive psychiatric evidence as a whole, as set forth above, and having given particular attention to the Veteran’s testimony, the Board finds that the Veteran’s PTSD symptoms prior to April 19, 2018 more nearly approximate occupational and social impairment, with reduced reliability and productivity due to associated symptoms and thereafter currently more nearly approximate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to associated symptoms, suggested by or similar to the criteria set forth under the General Rating Formula. Consequently, the Veteran’s claim for a higher disability evaluation in excess of 50 percent prior to April 19, 2018 is denied and thereafter is granted at a 70 percent rating, but no higher. The Board has considered the benefit-of-the-doubt doctrine. However, where the Board has not ruled favorably for the Veteran, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, 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.