Citation Nr: 23009019 Decision Date: 02/10/23 Archive Date: 02/10/23 DOCKET NO. 18-28 435A DATE: February 10, 2023 ORDER Beginning June 20, 2019, a 30 percent rating, but not higher, for right forearm strain with painful motion of the elbow pursuant to DC 5206, is granted. Prior to June 20, 2019, and from April 1, 2021, a rating higher than 10 percent for right forearm strain with limited pronation, is denied. From June 20, 2019 to April 1, 2021, a rating higher than 30 percent for right forearm strain with limited pronation, is denied. Entitlement to a rating higher than 10 percent for a right knee strain is denied. Entitlement to a rating higher than 10 percent for a left knee strain is denied. Prior to June 20, 2019, a 30 percent rating, but not higher, for bilateral plantar fasciitis, is granted. From June 20, 2019 to April 1, 2021, a rating higher than 30 percent for bilateral plantar fasciitis is denied. Beginning April 1, 2021, a 30 percent rating, but not higher, for bilateral plantar fasciitis, is granted. Prior to May 24, 2018 and from April 1, 2021, forward, a rating higher than 70 percent for posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to an initial rating higher than 20 percent for a right shoulder disability is remanded. FINDINGS OF FACT 1. Beginning June 20, 2019, the Veteran's right forearm strain with painful motion of the elbow more nearly approximated limitation of flexion to 70 degrees. 2. Prior to June 20, 2019 and from April 1, 2021, the right forearm strain with limited pronation did not approximate pronation where motion is lost beyond the last quarter arc, where the hand does not approach full pronation. 3. From June 20, 2019 to April 1, 2021, the right forearm strain with limited pronation did not approximate loss of forearm pronation (bone fusion), with the hand fixed in supination or hyperpronation. 4. During the entire initial rating period on appeal, the Veteran's right knee strain manifested by pain with flexion limited to no worse than 70 degrees and normal extension even during flare-ups and after repeated use over time. 5. During the entire initial rating period on appeal, the Veteran's left knee strain manifested by pain with flexion limited to no worse than 70 degrees and normal extension even during flare-ups and after repeated use over time. 6. For the entire rating period on appeal, the bilateral plantar fasciitis resulted in severe symptoms. 7. Prior to May 24, 2018 and from April 1, 2021, forward, the Veteran's PTSD does not more nearly approximate total occupational and social impairment. From May 24, 2018 to April 1, 2021, the Veteran PTSD is rated as 100 percent disabling. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating, but not higher, for right forearm strain with painful motion of the elbow are approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.71a Diagnostic Code (DC) 5206. 2. Prior to June 20, 2019, and from April 1, 2021, forward, the criteria for a rating higher than 10 percent for right forearm strain with limited pronation are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, DC 5213. 3. From June 20, 2019 to April 1, 2021, the criteria for a rating higher than 30 percent for right forearm strain with limited pronation are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, DC 5213. 4. The criteria for a rating higher than 10 percent for a right knee strain are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.59, 4.7, 4.71a, Diagnostic Code (DC) 5260. 5. The criteria for a rating higher than 10 percent for a left knee strain are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.59, 4.7, 4.71a, Diagnostic Code (DC) 5260. 6. Prior to June 20, 2019, and from April 1, 2021, forward, the criteria for a 30 percent rating for bilateral plantar fasciitis are approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, DC 5276-5269. 7. From June 20, 2019 to April 1, 2021, the criteria for a 30 percent rating for bilateral plantar fasciitis are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, DC 5276-5269. 8. Prior to May 24, 2018 and from April 1, 2021, forward, the criteria for an initial rating higher than 70 percent for PTSD are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1977 to March 1977, from November 1984 to March 1985 and from May 1986 to November 1991. He had additional service with the Army National Guard of Pennsylvania. Procedural History In December 2012, VA received the Veteran's increased rating claims for plantar fasciitis, right forearm strain, right knee, and left knee disabilities, as well as service connection claims for PTSD and a right shoulder disability. In a January 2014 rating decision, the RO denied the increased rating claims (a rating higher than 10 percent for plantar fasciitis, and compensable rating for right forearm strain, right knee, and left knee) and granted service connection for PTSD with an initial 70 percent rating, and right shoulder disability with an initial noncompensable rating. In July 2014, the Veteran timely appealed the decision. Thereafter, by a January 2018 rating decision, the RO increased the right shoulder disability rating to 20 percent for the entire initial rating period on appeal, the right and left knees to 10 percent for the entire rating period on appeal, and the right forearm strain to 10 percent for the entire rating period on appeal. A statement of the case (SOC) was issued in April 2018 and the Veteran timely perfected his appeal in June 2018. In the interim, the Veteran submitted a NOD with the January 2018 rating decision despite the issues being already on appeal. In an August 2019 rating decision, the RO increased the PTSD rating to 100 percent effective May 24, 2018, plantar fasciitis to 30 percent effective June 20, 2019, right forearm to strain to 30 percent, effective June 20, 2019, and granted a separate 20 percent rating for right forearm painful motion of the elbow, effective June 20, 2019. A supplemental statement of the case (SSOC) was issued in September 2019. Thereafter, in an October 2020 rating decision, the RO granted entitlement to a TDIU effective May 24, 2018 (the claim for an earlier effective date for this grant is pending under the AMA framework and will not be discussed herein). The decision denied a rating higher than 20 percent for a right shoulder disability and higher than 10 percent for right and left knee disability. The decision then proposed to decrease the rating for PTSD from 100 to 70 percent, plantar fasciitis from 30 to 10 percent, right forearm strain from 30 to 10 percent, and right forearm limitation of motion of the elbow from 20 to 10 percent. Four days later, the Board remanded the issues of entitlement to a rating higher than 70 percent prior to May 24, 2018, for PTSD, a rating higher than 20 percent for a right shoulder disability, a rating higher than 10 percent prior to June 20, 2019 and higher than 30 percent thereafter, for bilateral plantar fasciitis, a rating higher than 10 percent for right and left knee disabilities, a rating higher than 10 percent prior to June 20, 2019, and higher than 30 percent thereafter, for right forearm strain, and a rating higher than 20 percent for right forearm strain with painful motion of the elbow for the issuance of a SSOC. A SSOC was issued three days later. While the appeal was awaiting further review by the Board and under the Board's jurisdiction, the RO issued a January 2021 rating decision, which confirmed the proposed reduction as noted above, effective April 1, 2021. The Veteran filed a VA Form 20-0996 Request for Higher-Level Review with the reduction, which the RO confirmed and continued in an April 2021 rating decision. This decision was not appealed to the Board under the AMA framework. Nevertheless, the Board finds that the entire rating period on appeal from December 13, 2012 to the present is properly before the Board. Specifically, the Board will address the entire period as staged ratings. Lastly, the claim for an earlier effective date for the award of a TDIU is pending under the AMA framework and will be decided at a later time. Increased Rating Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where the veteran is appealing the rating for an already established service-connected condition, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). Right Forearm Strain with Painful Motion of Elbow/with Limited Pronation Rating Criteria The right forearm strain with painful motion of the elbow is rated as 20 percent disabling from June 20, 2019 to April 1, 2021, and as 10 percent disabling thereafter, pursuant to DC 5206. The right forearm strain with limited pronation is rated pursuant to DC 5213. From December 13, 2012 to June 20, 2019, it is rated as 10 percent disabling, from June 20, 2019 to April 1, 2021 it is rated as 30 percent disabling, and beginning April 1, 2021, it is rated as 10 percent disabling. Under DC 5206, a 0 percent rating is warranted when forearm flexion of the major arm is limited to 110 degrees; a 10 percent rating is warranted when forearm flexion of the major arm is limited to 100 degrees; a 20 percent rating is warranted when forearm flexion is limited to 90 degrees; a 30 percent rating is warranted when forearm flexion is limited to 70 degrees; a 40 percent rating is warranted when forearm flexion is limited to 55 degrees; and a 50 percent rating is warranted when forearm flexion is limited to 45 degrees. 38 C.F.R. § 4.71a. Normal range of motion of the elbow is from 0 degrees of extension to 145 degrees of flexion. 38 C.F.R. § 4.71a. Plate I. Normal forearm pronation is from zero to 80 degrees. Id. Normal forearm supination is from zero to 85 degrees. Id. Under DC 5213, limitation of supination to 30 degrees or less warrants a 10- percent rating. Limitation of pronation where motion is lost beyond the last quarter arc, where the hand does not approach full pronation, warrants a 20-percent rating. Motion lost beyond the middle arc in the major extremity warrants a 30- percent rating. 38 C.F.R. § 4.71a, DC 5213. Normal forearm pronation is from 0 to 80 degrees, and normal forearm supination is from 0 to 85 degrees. 38 C.F.R. § 4.71a. Plate I. Right Forearm Strain with Painful Motion of Elbow/with Limited Pronation Evidence and Rating Analysis In February 2013, the Veteran underwent VA examinations, to include for a right forearm strain. The examiner noted that the Veteran was right hand dominant. Active and passive motion of the elbow revealed flexion to 140 degrees and hyperextension to 0 degrees. Pronation of the forearm was to 80 degrees and supination was to 80 degrees. There was no additional loss of motion after repetitive use testing. Range of motion was not additionally limited by pain, fatigue, weakness, or lack of endurance. The Veteran reported that he had chronic discomfort and used Advil, which was beneficial. There was tenderness on palpation of the forearm. Muscle strength testing was normal (5/5). There was no ankylosis or any other condition. The disability did not impact his ability to work as a bus driver. According to VA treatment records dated from 2013 to 2019, the Veteran continued to complain of right forearm/elbow pain. In June 2019, the Veteran underwent elbow and forearm conditions compensation examination, at which time the examiner rendered a diagnosis of strain of other muscles, fascia and tendons at forearm level, right arm, subsequent encounter. The Veteran reported "snapping sound" and achiness without specific motion. Right elbow flare-ups occurred weekly, were moderate to severe, and lasted 30 minutes to one hour. Functional loss/impairment was described as pain with reaching and straightening the arm. Upon physical examination, range of motion of the right elbow revealed flexion to 100 degrees, extension from 100 to 0, and forearm supination and pronation to 70 degrees. Pain was noted on examination and resulted in a functional loss. There was no objective evidence of localized tenderness or pain on palpation. There was objective evidence of crepitus. There was no additional loss of function or range of motion after repetitive use testing. The examiner estimated that after repeated use over time and/or during flare-ups, range of motion would result in flexion to 75 degrees, extension 75 to 0 degrees, and forearm supination and pronation to 40 degrees. Additional factors contributing to the disability included increased pain with extension and flexion activities. Muscle strength testing was normal (5/5) without evidence of muscle atrophy. There was no ankylosis or any other condition. In September 2020, the Veteran underwent another VA elbow and forearm conditions compensation examination, at which time the examiner confirmed a diagnosis of right forearm strain with limited pronation (dominant). The Veteran reported "clicking" sound from the elbow with intermittent pain. He took no medications for treatment and denied having flare-ups. Functional loss/impairment was described as difficulty with pushing/pulling/lifting/holding more than 15 pounds, carrying bags, and reaching upwards above shoulders. Upon physical examination, range of motion revealed flexion to 140 degrees, extension to 0 degrees, forearm supination to 85 degrees, and forearm pronation to 80 degrees. Pain was noted on examination but did not result in/cause functional loss. There was no objective evidence of localized tenderness or pain on palpation. There was objective evidence of crepitus. There was no additional loss of function or range of motion after repetitive use testing. The examiner estimated that after repeated use over time and/or during flare-ups, range of motion would result in flexion to 135 degrees. Muscle strength testing showed active movement against some resistance (4/5) without evidence of muscle atrophy. The examiner estimated that after repeated use over time and/or during flare-ups, range of motion would result in flexion to 75 degrees, extension 75 to 0 degrees, and forearm supination and pronation to 40 degrees. Analysis Pursuant to DC 5206, the Veteran's forearm limitation of flexion was noncompensable prior to the June 2019 examination. As noted above, prior to this, range of motion was slightly limited to 140 degrees. Even applying the 2019 estimation of additional 25-degrees loss of motion after repeated use/during flare-ups, a compensable rating is not approximated. As discussed, the rating pursuant to DC 5206 is in effect since June 20, 2019, at which time it is rated as 20 percent disabling until April 1, 2021, and as 10 percent disabling thereafter. On review, the Board finds that a 30 percent rating is warranted beginning June 20, 2019. The June 2019 examiner estimated that during flare-ups/after repeated use over time, flexion of the forearm will decrease to 75 degrees. The criteria for a 20 percent rating contemplates limitation of flexion to 90 degrees, and the criteria for a 30 percent rating contemplates limitation of flexion to 70 degrees. The Board finds that based on the above evidence, the criteria for a 30 percent (limitation of flexion to 70 degrees) is more nearly approximated. The Board assigns little to no probative weight to the September 2020 examination report. Specifically, despite the Veteran's reported flare-ups throughout the pendency of the claim, this examiner noted that the Veteran had no flare-ups, yet estimated only a 5-degree reduction after repeated use over time/during flare-ups. In any event, the Board does not find this examination report as sufficient evidence of an improvement under the ordinary conditions of life and work. Accordingly, beginning June 20, 2019, a 30 percent rating, but not higher, for right forearm strain with painful motion of the elbow, is warranted. A rating higher than 30 percent is not warranted as limitation of flexion to 55 degrees is not more nearly approximated even during flare-ups or after repeated use over time. Pursuant to DC 5213, the Board finds that a rating higher than 10 percent from December 13, 2012 to June 20, 2019, higher than 30 percent from June 20, 2019 to April 1, 2021 and higher than 10 percent beginning April 1, 2021, is not warranted. On review, the Board finds that a rating higher than 10 percent prior to June 20, 2019 and from April 1, 2021, forward is not warranted. The evidence does not indicate limitation of pronation characterized by motion lost beyond the last quarter arc, where the hand does not approach full pronation, which would be required for a 20-percent evaluation under DC 5213. The limitation of supination is already contemplated by the assigned 10 percent rating. The evidence is against finding limitation of pronation approximating motion lost beyond middle of arc, which would be required for a higher, 30-percent rating under DC 5213. As noted, the forearm pronation was estimated to be limited to 40 degrees, at worse, during a flare-up/after repeated use over time. The Board determines that from June 20, 2019 to April 1, 2021, the evidence is against finding loss of forearm pronation (bone fusion), with the hand fixed in supination or hyperpronation, which would be required for higher, 40-percent rating under DC 5213. There has been no ankylosis of the right elbow. The Board will not disturb the already assigned 30 percent rating from June 20, 2019 to April 1, 2021; however, a rating higher than 10 percent and 30 percent is not warranted at any point during the pendency of the claim. Knees Rating Criteria The Veteran's right and left knees are rated pursuant to DC 5260. Knee disabilities can be rated under Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, 5262, and 5263. 38 C.F.R. § 4.71a. DC 5257 provides a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate" and "severe" as used in various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6; Spellers v. Wilkie, 30 Vet. App. 157 (2018). Under DC 5257, effective February 7, 2021, a 10 percent rating is warranted for recurrent subluxation or instability for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. For patellar instability under DC 5257, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker; a 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker; and a 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. DC 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. DC 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a. DC 5260 provides for the evaluation of limitation of flexion of the knee. A non-compensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a. Under DC 5263, genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. 38 C.F.R. § 4.71a. Genu recurvatum is hyperextension of the knee. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (30th Ed. 2003) at 765. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. 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 disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Knees Evidence and Rating Analysis In February 2013, the Veteran underwent VA examinations, to include for the bilateral knee strain. The Veteran reported chronic pain especially when walking. Advil sometimes helped relieve the pain. Upon physical examination, range of motion revealed flexion to 115 degrees with normal extension, bilaterally. There was no additional limitation of motion after repetitive use testing. Range of motion was not additionally limited by pain, fatigue, weakness, or lack of endurance. There was no pain on palpation, painful motion, or tenderness, bilaterally. There was no patellar subluxation or dislocation, bilaterally. There was no meniscal condition, bilaterally. The Veteran used no assistive devices. The bilateral knee strain did not impact the Veteran's ability to work as a bus driver. According to VA treatment records dated from 2013 to 2019, the Veteran continued to complain of bilateral knee pain. In June 2019, the Veteran underwent a knee compensation examination, at which time the examiner confirmed a diagnosis of bilateral knee strain. The Veteran reported bilateral knee weakness, pain when climbing stairs, and increased pain with weather changes. The Veteran used bilateral over the counter knee braces and Ibuprofen for treatment. Flare-ups were described as occurring once or twice per month, lasting 2 to 7 days, and were moderate to severe, bilaterally. The flare-ups were alleviated by icy-hot cream and Ibuprofen. Functional loss/impairment was described as increased pain with walking more than 1 block, climbing, running, raising from a sitting to a standing position, climbing more than 1 flight of stairs and standing for more than 45 minutes. Upon physical examination, range of motion of both knees revealed flexion to 95 degrees with normal extension. Pain was noted on examination and caused functional loss. There was no localized tenderness/pain on palpation. There was evidence of pain with weightbearing and objective evidence of crepitus, bilaterally. There was no additional loss of function or motion after three repetitions, bilaterally. The examiner estimated that after repeated use over time and/or during flare-ups, flexion will decrease to 70 degrees, bilaterally. Additional factors contributing to the disability included disturbance of locomotion and interference with sitting/standing. Muscle strength testing showed active movement against some resistance (4/5), bilaterally, without evidence of muscle atrophy. There was no ankylosis, bilaterally. There was no history of recurrent subluxation/lateral instability or recurrent effusion, bilaterally. Joint stability testing was normal, bilaterally. There was no evidence of patellar subluxation or a meniscus condition, bilaterally. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right or left knee strain. The Veteran used a cane regularly for stability. X-rays showed no evidence of arthritis. In September 2020, the Veteran underwent another VA knee examination, at which time the examiner confirmed a diagnosis of bilateral knee strain. The Veteran reported chronic pain but denied having flare-ups. Functional loss/impairment was described as unstable side to side lateral movement if moving fast, difficulty going up and down stairs, inability to climb ladders or run, pain with walking more than 15 minutes, painful lifting, and kneeling, and needing to change position every 15 minutes. Upon physical examination, range of motion of both knees revealed forward flexion to 135 degrees with normal extension. Pain was noted on examination and caused functional loss. There was no localized tenderness/pain on palpation. There was evidence of pain with weightbearing and objective evidence of crepitus, bilaterally. There was no additional loss of function or motion after three repetitions, bilaterally. The examiner estimated that after repeated use over time, flexion will decrease to 130 degrees, bilaterally. Muscle strength testing was normal (5/5) without evidence of muscle atrophy or any muscle reduction. There was no ankylosis, bilaterally. There was no history of recurrent subluxation/lateral instability or recurrent effusion, bilaterally. Joint stability testing was normal, bilaterally. There was no evidence of patellar subluxation or a meniscus condition, bilaterally. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right or left knee strain. The Veteran used a walker. Analysis Right Knee For the reasons expressed below, the Board finds that a rating higher than 10 percent is not warranted based on limitation of motion of the right knee. Initially, a rating higher than 10 percent is not warranted pursuant to DC 5260 even considering functional loss after repeated use and/or during flare-ups. Notably, at worse, flexion of the knee was to 70 degrees (during flare-ups/after repeated use over time as estimated by the 2019 examiner). In other words, flexion to 30 degrees is not met or approximated even during flare-ups or after repeated use over time. Similarly, a higher rating pursuant to DC 5261 is also not warranted. As discussed above, extension was normal throughout the pendency of the claim. Even considering flare-ups and repeated use over time, limited extension to 10 degrees is not met or approximated. The Board also considered the applicability of other potential diagnostic codes during this period on appeal. As the evidence of record fails to demonstrate ankylosis; instability; cartilage removal; meniscus impairment; impairment of the tibia or fibula; or genu recurvatum, the Veteran is not entitled to a higher or separate rating under DCs 5256, 5257, 5258, 5259, 5262, or 5263 respectively. Left Knee For the reasons expressed below, the Board finds that a rating higher than 10 percent is not warranted based on limitation of motion of the left knee. Initially, a rating higher than 10 percent is not warranted pursuant to DC 5260 even considering functional loss after repeated use and/or during flare-ups. Notably, at worse, flexion of the knee was to 70 degrees (during flare-ups/after repeated use over time as estimated by the 2019 examiner). In other words, flexion to 30 degrees is not met or approximated even during flare-ups or after repeated use over time. Similarly, a higher rating pursuant to DC 5261 is also not warranted. As discussed above, extension was normal throughout the pendency of the claim. Even considering flare-ups and repeated use over time, limited extension to 10 degrees is not met or approximated. The Board also considered the applicability of other potential diagnostic codes during this period on appeal. As the evidence of record fails to demonstrate ankylosis; instability; cartilage removal; meniscus impairment; impairment of the tibia or fibula; or genu recurvatum, the Veteran is not entitled to a higher or separate rating under DCs 5256, 5257, 5258, 5259, 5262, or 5263 respectively. Plantar Fasciitis Rating Criteria The Veteran's bilateral plantar fasciitis is rated pursuant to DC 5276 for pes planus. From December 13, 2012, to June 20, 2019, the disability is rated as 10 percent disabling, from June 20, 2019 to April 1, 2021, the disability is rated as 10 percent disabling. Pursuant to DC 5276, a 10 percent rating is warranted for moderate unilateral or bilateral flatfoot, to include with characteristics of weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. A 20 percent rating is warranted for unilateral, and a 30 percent rating is warranted for bilateral severe bilateral flatfoot, to include with characteristics of objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for unilateral, and a maximum 50 percent rating is warranted for pronounced bilateral flatfoot, to include with characteristics of marked pronation, extreme tenderness of plantar surfaces, marked inward displacement and severe spasms of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. Though, the Board notes that during the pendency of the claim, pursuant to the revised rating schedule, under DC 5269, a 30 percent rating for plantar fasciitis when there is no relief from both non-surgical and surgical treatment bilaterally and a 20 percent rating is warranted when there is no relief from both non-surgical and surgical treatment unilaterally. A 10 percent rating is warranted for either unilateral or bilateral plantar fasciitis when the 20 and 30 percent criteria are not met. The regulations provide that when a veteran is recommended for surgical intervention, but is not a candidate, the disability should be rated under the 20 or 30 percent criteria. 38 C.F.R. § 4.71a, DC 5269, Note (2). The terms "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Plantar Fasciitis Evidence and Rating Analysis In February 2013, the Veteran underwent VA examinations, to include for plantar fasciitis. The Veteran reported having constant pain in the soles of the feet. He used Advil 15 times a week for pain, which sometimes was helpful. He could stand and walk for an hour. There was no Morton neuroma, metatarsalgia, hallux valgus/rigidus, pes cavus, malunion of bones, foot injury, weak foot, or scars. The Veteran used inserts, which were somewhat helpful. The examiner noted that the Veteran was a part-time bus driver, and the plantar fasciitis caused no problems with his ability to work. According to VA treatment records dated from 2013 to 2019, the Veteran continued to complain of bilateral foot pain. In June 2019, the Veteran underwent a foot compensation examination, at which time the examiner confirmed a diagnosis of bilateral plantar fasciitis. The Veteran reported bilateral foot pain and swelling after physical activity. He used over the counter orthotics to help with the discomfort. The pain was described as really sore and hurting to walk. Flare-ups and functional loss/impairment were described as pain with walking less than 500 feet with pain worst in the morning, lasting one to two hours. There was pain on use and pain on manipulation of the feet, bilaterally. The pain was accentuated on use and manipulation, bilaterally. There was no indication of swelling on use or characteristic calluses. There was no extreme tenderness of the plantar surfaces of either foot. There was no evidence of decreased longitudinal arch height, objective evidence of marked deformity, or marked pronation, bilaterally. There was no "inward" bowing or marked inward displacement and severe spasm of the achilles tendon. There was pain on physical examination, which contributed to functional loss. Contributing factors of the disability included excess fatigability, pain on movement, pain on weightbearing, disturbance of locomotion, and interference with sitting and standing. Pain significantly limited functional ability during flare-ups and/or after repeated use over a period of time. This occurred two to four times per month, at which time pain was moderate and lasted two to three hours. Pain was relieved by pain medication and rest. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right or left foot plantar fasciitis. The Veteran used a cane regularly for stability. The examiner noted that the Veteran used no arch support, built up shoes, or orthotics. In September 2020, the Veteran underwent another foot conditions examination, at which time the examiner confirmed a diagnosis of bilateral plantar fasciitis. The Veteran reported chronic pain but denied having flare-ups. he stated that the feet hurt all the time. The examiner noted no pain on use or on manipulation of the feet. There was no swelling on use but there were characteristic calluses. Orthotics relieved symptoms, bilaterally. There was no extreme tenderness of plantar surfaces. There was pain on physical examination, which contributed to a functional loss. Factors contributing to the disability included excess fatigability, incoordination, pain on movement and with weightbearing, instability of station, disturbance of locomotion, and interference with sitting and standing. Regarding the impact of pain if the feet were used repeatedly over a period of time, the examiner noted that without orthotics, the Veteran could not walk more than 15 minutes and could not run. On review, the Board finds that the most adequate examination is the June 2019 examination, which took into account the Veteran's lay reports and medical history. The 2013 examination was cursory at best and included a one paragraph summary of the Veteran's bilateral plantar fasciitis. Though, even at that time, the Veteran reported constant foot pain that was only sometimes relieved by pain killers. The 2019 examiner to consider and conclude that pain significantly limited functional ability during flare-ups and/or after repeated use over a period of time. The Board finds the subsequent 2020 examination inconsistent with the evidence of record. Specifically, the examiner noted that the Veteran denied having flare-ups and had no pain on use or manipulation, contrary to the Veteran's reports. As such, the Board finds that for the entire rating period on appeal, the bilateral plantar fasciitis resulted in severe symptoms of pain that were only partially relieved by medications and orthotics. Accordingly, resolving any doubt in the Veteran's favor, a 30 percent rating is granted for the entire rating period on appeal. A rating higher than 30 percent pursuant to DC 5276 is not warranted as there were no symptoms of pronounced bilateral flatfoot, to include with characteristics of marked pronation, extreme tenderness of plantar surfaces, marked inward displacement and severe spasms of the tendo Achillis on manipulation that were not improved by orthotics. Here, as discussed above, orthotics provided at least some relief. PTSD Rating Criteria The Veteran's PTSD is rated as 70 percent disabling prior to May 24, 2018, as 100 percent disabling from May 24, 2018 to April 1, 2021, and as 70 percent disabling thereafter. The criteria for rating psychiatric disabilities, other than eating disorders, are set forth in the General Rating Formula (General Rating Formula) for Mental Disorders. See 38 C.F.R. § 4.130. Under the General Rating Formula, a 70 percent rating is warranted if the evidence establishes 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); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted 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. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general Rating Formula for mental disorders is 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; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. When it is not possible to separate the effects of a service-connected disability and a nonservice-connected disability, reasonable doubt must be resolved in the appellant's favor and the symptoms in question must be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale, and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. The increased rating claim for the acquired psychiatric disorder was pending prior to August 4, 2014 and this specific appeal was certified to the Board after August 2014, and as such, both the DSM-IV and DSM-V apply. Nevertheless, because of the Court's emphatic pronouncement in Golden that the GAF scores are methodologically flawed and are particularly unreliable as applied to psychiatric disorders, in this decision, the Board will place no reliance on GAF scores for rating this Veteran's psychiatric disorder. PTSD Evidence and Rating Analysis In April 2013, the Veteran underwent a VA PTSD examination, at which time the examiner confirmed diagnoses of PTSD and major depressive disorder (MDD). The examiner indicated that symptoms of PTSD and MDD could be differentiated. The examiner explained that some symptoms were associated with both disorders such as impaired sleep and concentration, irritability, and social withdrawal. However, PTSD symptoms included intrusive memories, flashbacks, distressing dreams, making efforts to avoid the thoughts related to the trauma, and hypervigilance. MDD symptoms included depressed mood most of the time, anhedonia, excessive guilt, low energy, poor appetite, feeling of hopelessness, loneliness, and worthlessness, and suicidal ideation. In terms of social impairment, the examiner noted that the Veteran described having a good relationship with his mother. He was detached from his twin brother. He was married since 1994. He had no children from the marriage but had three stepchildren. He stated that he had a good relationship with his spouse. He was detached from his stepchildren and only saw his stepdaughter occasionally. His spouse was the main source of his social support. His mother was also very helpful and supportive. He also reported having a few friends but noted that compared to friendship he had prior to service, his current friendship network was weak. He denied having any significant activities outside of work or home. He was an inactive member of VFW. In terms of occupational impairment, the Veteran worked part-time as a bus driver. The Veteran reported that his work was not going well and that he quit last year, requested to come back, but now considered quitting again. He had some conflict with his supervisor. Prior to this job, he had his own carpentry job for twelve years, which did well but he left the business due to the recession and his family encouraged him to relocate. The examiner identified symptoms of depressed mood; anxiety; near continuous panic/depression affecting ability to function independently, appropriately, and effectively; flattened affect; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting; and suicidal ideation. The Veteran was competent to manage his financial affairs. On mental status examination, the Veteran was fully oriented and appropriately dressed and groomed. Speech was normal. Behavior was appropriate. There was no evidence or reports of delusions or hallucinations. Mood was depressed and affect flat. The examiner concluded that the PTSD resulted in 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. The examiner stated that MDD resulted in lack of motivation and lower energy, which impaired the Veteran's ability to initiate or continue to follow through socially and occupationally. PTSD resulted in significant impairment in occupational functioning. In support of his claim, the Veteran submitted a private May 2018 PTSD disability benefits questionnaire. The clinical psychologist rendered a diagnosis of PTSD. In terms of social impairment, the clinical psychologist noted that the Veteran was married with no children and was unable to maintain healthy intimate social relationships due to PTSD. He was antisocial, had social anxiety, and avoided people. He was detached from family/peers and got angry and irritable easily in social situations. He had difficulty communicating and getting along with others, especially in social and work settings. In terms of occupational impairment, the clinical psychologist noted that the PTSD continuously impaired his ability to maintain consistent employment and that the Veteran did not work since 2014. The clinical psychologist identified PTSD symptoms of depressed mood; anxiety; suspiciousness; panic attacks that occurred weekly or less often; near-continuous panic/depression affecting ability to function independently, appropriate, and effectively; chronic sleep impairment; mild memory loss; impairment of short and long term memory; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; suicidal ideation; obsessional rituals which interfere with routine activities; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living; and disorientation to time or place. The clinical psychologist concluded that the PTSD resulted in occupational and social impairment with deficiencies in most areas. In June 2019, the Veteran underwent a PTSD compensation examination, at which time the examiner rendered diagnoses of PTSD and alcohol use disorder. The examiner indicated that it was possible to differentiate the symptoms of the two disorders but then noted that alcohol use was considered secondary to PTSD. In terms of social impairment, the examiner noted that the Veteran lived with his spouse of 25 years. He had no children. He had a positive relationship with his mother. He had two brothers that he had no relationship with. He did not spend time socially with others and mostly kept to himself. Hobbies and interests included "taking things apart." In terms of occupational impairment, the examiner noted that the Veteran was medically retired 2012. Prior to this, he worked as a bus driver and had a remodeling business. The examiner identified PTSD symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; suicidal ideation; and impaired impulse control. On mental status examination, the Veteran was fully oriented, fairly groomed, and casually dressed. Speech was normal. Mood was neutral. Concentrated and long-term memory were intact but short-term memory was impaired. Insight was fair and judgment poor. He denied experiencing suicidal or homicidal thoughts during the examination. He was capable of managing his financial affairs. The examiner concluded that the PTSD resulted in occupational and social impairment with reduced reliability and productivity. In September 2020, the Veteran underwent another PTSD compensation examination, at which time the examiner rendered diagnoses of PTSD, unspecified depressive disorder partly secondary to PTSD, and alcohol use disorder secondary to PTSD. The examiner stated that symptoms of the disorders could not be differentiated. In terms of social impairment, the examiner noted that the Veteran lived with his spouse of 26 years and had a good relationship with her. He had no children, and he did not communicate with his stepchildren. He had a good relationship with his mother. He did not have a relationship with his brothers. He had a few friends who he socialized with "every so often." In terms of occupational impairment, the examiner noted that the Veteran was unemployed and left his job as a bus driver in 2014 after an injury. The examiner identified PTSD symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty adapting to stressful circumstances including work or a worklike setting. On mental status examination, the Veteran was properly dressed and adequately groomed. Speech was normal. There was no evidence of hallucinations or delusions. Affect was restricted but not flat and mood was dysthymic. Insight and judgment were fair. The examiner concluded that the PTSD resulted in occupational and social impairment with reduced reliability and productivity. On review, the Board finds that a rating higher than 70 percent is not warranted. In terms of occupational impairment, the Board specifically considered evidence suggesting that the Veteran's PTSD impacted his ability to work; however, as noted above, the issue of entitlement to a TDIU is still pending. In addition, TDIU is in effect since May 24, 2018. In addition, the Veteran has not been totally socially and occupationally impaired due to the PTSD. He was found capable of managing his own financial affairs and appeared fully oriented throughout the pendency of the appeal. On mental status examinations, he always presented as adequately dressed and groomed and as such there was no evidence of neglect in hygiene. There was also no evidence of delusions or hallucinations at any time during the pendency of the appeal. Moreover, although his PTSD resulted in social impairment, such impairment was not considered "total." As discussed above, despite his difficulties, he continued to maintain at least some relationships with his mother and spouse and reported having some friends despite not establishing new relationships or seeing those friends regularly. The Board acknowledges that the Veteran received a 100 percent rating from May 24, 2018 to April 1, 2021 based on the private May 2018 disability benefits questionnaire, in which the clinical psychologist checked the box for disorientation to time or place, which is listed under the criteria for a 100 percent rating. While the Board will not disturb the assigned 100 percent rating during this period, it emphasizes that even this clinical psychologist concluded that the PTSD resulted in occupational and social impairment with deficiencies in most areas. Moreover, the evidence of record, to include during the May 2018 interview with the clinical psychologist contradicts the notation that the Veteran's PTSD resulted in disorientation to time or place. In fact, the clinical psychologist concluded that the Veteran was fully oriented, which is consistent with all mental health treatment and examinations throughout the pendency of the claim. Total occupational and social impairment generally requires symptoms severe enough to severely distort the individual's perception of reality, which has been not shown by the record. Overall, the Veteran's psychiatric symptoms do not equate in severity, frequency, or duration to total occupational and social impairment, nor have the symptoms demonstrated a level of severity in symptomatology to approximate or equate to that in the symptoms listed for a 100 percent rating. Additionally, the identified PTSD symptoms of chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and suicidal ideation, are properly contemplated by the currently assigned 70 percent disability rating. Finally, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). REASONS FOR REMAND The Board finds the 2019 and 2020 shoulder conditions examinations inadequate. Specifically, both examiners confirmed only a diagnosis of a right shoulder strain. The examination reports stated that the Veteran had no other right shoulder condition, to include clavicle, scapula, AC joint, or sternoclavicular joint condition. In addition, both examiners noted that x-rays showed no evidence of arthritis. Nevertheless, both examiners failed to address or review a 2014 MRI study, which showed large tear at the base of the entire posterior labrum, mild diffuse rotator cuff tendinosis without a rotator cuff tendon tear, moderate degenerative changes with mild AC joint impingement and mild subacromial/subdeltoid bursitis, and mild glenohumeral degenerative arthritis. A new examination is necessary to determine the current severity and to confirm all relevant diagnoses associated with the right shoulder disability. The matters are REMANDED for the following action: 1. Provide the Veteran with a VA examination to help determine the current severity of the service-connected right shoulder disability. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed right shoulder disabilities. In doing so, specifically address the July 2014 MRI study. See VBMS entry titled "Medical Treatment Records - Furnished by SSA" on 04/01/2020 p.64. Please specifically explain any discrepancies. (b) The examiner should interview the Veteran regarding any current flare-ups and those reported during the pendency of the claim and solicit evidence from him on the amount of impairment experienced during such. The examiner should then describe how the Veteran's functional ability was affected during flare-ups expressed in degrees of range of motion, if possible. Note: The Court has held that an examiner cannot decline to assess the impact of a Veteran's flare-ups only because the examiner did not observe during a flare-up or after repeated use over time. A complete rationale should be provided for all opinions. (Continued on the next page) 2. Thereafter, readjudicate the remanded claim. M. Schlickenmaier Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Yaffe, 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.