Citation Nr: 0005485 Decision Date: 02/29/00 Archive Date: 09/08/00 Citation Nr: 0005485 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 94-14 935A ) DATE ) RECONSIDERATION ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an increased rating for residuals of right knee injury, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma, currently evaluated as 20 percent disabling. 2. Entitlement to an increased rating for traumatic arthritis of the right knee, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Andrew E. Betourney, Associate Counsel INTRODUCTION The veteran served on active duty from July 1966 to May 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 1994 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which granted an increased rating for the veteran's right knee disorder from 10 percent to 20 percent. The veteran filed a timely appeal to the disability rating assigned. On December 7, 1998, the Board issued a decision granting an increased rating to 30 percent for the veteran's right knee disorder. On March 2, 1999, the Board, on its own motion, by the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991 & Supp. 1998), ordered reconsideration of the December 7, 1998 Board decision on the issue of an increased rating for residuals of right knee traumatic arthritis, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma. The case is now before an expanded reconsideration panel of the Board. This decision by the reconsideration panel replaces that part of the decision of December 7, 1998 which addressed veteran's claim for an increased rating for his right knee disorder, and is the final decision of the Board as to that issue. The Board notes that the issue of an increased rating for post- traumatic stress disorder was not the subject of this reconsideration order, and, as such, the Board's December 7, 1998 decision as to that issue only is final and is not presently before the Board. In addition, the Board notes that while the RO's March 1994 decision on appeal listed both the veteran's right knee injury residuals and his right knee arthritis as one disability, the RO subsequently separated out the veteran's right knee arthritis as a distinct service-connected disorder in a rating decision dated in August 1998, and assigned a 20 percent disability rating thereto. Therefore, the Board finds that despite the fact that the March 1994 RO decision on appeal listed and rated both disorders as one single disability, both the issue of an increased rating for residuals of a right knee injury and the issue of an increased rating for right knee arthritis are on appeal, and are both properly before the Board at this time. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained by the RO. 2. The veteran's residuals of right knee injury, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma, are currently manifested by minimal findings of instability, but with occasional incapacitating exacerbations, particularly following extended use of the knee; there is no medical evidence of more than moderate instability or subluxation of the right knee. 3. The veteran's traumatic arthritis of the right knee is currently manifested by x-ray evidence of arthritis of the right knee which results in slight limitation of knee motion, with range of flexion from 90 to 110 degrees and extension from 0 to 8 degrees; there are significant findings of painful motion, swelling, popping, and weakness of the knee which result in additional functional loss, but flexion is not limited to less than 30 degrees, and extension is not limited to more than 15 degrees. CONCLUSIONS OF LAW 1. The schedular criteria for a rating in excess of 20 percent for residuals of right knee injury, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.71a, Diagnostic Code 5257 (1999). 2. The schedular criteria for a rating in excess of 20 percent for traumatic arthritis of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.40, 4.45, Diagnostic Codes 5003, 5010, 5260, 5261 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A review of the record reveals that the veteran was originally granted service connection for torn medial cartilage of the right knee with osteoma of the right tibia and osteochondroma of the right fibula by a RO rating decision dated in May 1968, at which time a 20 percent disability evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257, effective May 3, 1968. Following a VA examination in October 1969, the RO reduced the 20 percent disability evaluation to a noncompensable (zero percent) evaluation for the right knee. A request from the veteran to reopen his claim for a higher rating for the service-connected right knee was received in April 1991. In October 1991, he was assigned a 10 percent disability evaluation for the right knee. At that time, the disability was termed "traumatic arthritis, right knee, with history of torn medial cartilage with osteoma of right tibia and osteochondroma, right fibula, post-operative meniscectomy," and the disability was rated under DC 5010-5003. In May 1993, the RO received a claim from the veteran for an increased disability rating. In March 1994, the RO issued a rating decision which increased the rating for the veteran's right knee disorder from 10 percent to 20 percent, effective May 14, 1993. At that time, the issue was termed "right knee, traumatic arthritis, meniscectomy, anterior cruciate ligament instability, with right tibial osteoma," and the disability was rated under DC 5010-5257. In August 1998, following several Board remands, the RO issued a rating decision which granted separate service connection for traumatic arthritis of the right knee, and assigned a disability evaluation of 20 percent for this arthritis under DC 5010. The RO continued the 20 percent rating for the veteran's general right knee injury residuals, including a right knee meniscectomy, with anterior cruciate ligament instability and right tibial osteoma, rated under DC 5257. On December 7, 1998, the Board issued a decision which granted an increased rating from 20 percent to 30 percent for the veteran's right knee disability, listed as one issue as "residuals of right knee traumatic arthritis, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma." However, since the Board combined the veteran's separately-rated residuals of right knee injury and his traumatic arthritis of the right knee into this one issue, this "increase" effectively amounted to a decrease in the veteran's overall disability rating, since the separate disabilities had each been rated as 20 percent disabling by the RO. Therefore, the Board, on its own motion, by the authority granted to the Chairman in 38 U.S.C.A. § 7103, ordered reconsideration of the December 7, 1998 Board decision on the issue of an increased rating for the veteran's right knee disorder. The veteran's claims for increased ratings for residuals of right knee injury and traumatic arthritis of the right knee are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (the Court) has held that a mere allegation that a service-connected disability has increased in severity is sufficient to render the claim well grounded. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). The Board is also satisfied that all relevant facts needed to adjudicate schedular evaluations of the veteran's disorders have been properly developed. No further assistance to the veteran is required on those issues to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (1999). I. Residuals of right knee injury, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma Evidence relevant to the current level of severity of the veteran's residuals of his right knee injury include the report of a VA examination conducted in June 1995. At that time, the veteran complained of pain and stiffness in the right knee in the evening, after being on his feet all day. The examiner noted that the veteran walked with a limp on the right and wore a hinged support brace on the right knee. Clinical examination revealed instability of the right knee and positive Drawer's sign. The examination also revealed some swelling and deformity of the right knee, including a bone protruding under the skin on the lateral side of the right knee. There was pain in the medial and lateral aspects of the right knee to the touch. Range of motion testing revealed extension to zero degrees, and flexion to 90 degrees. The examiner diagnosed an old shrapnel wound and cartilage and ligament tears from a helicopter jump. In February 1996, the veteran again underwent a VA joints examination. At that time, the veteran complained of pain, stiffness, and locking of the right knee, as well as swelling after walking or standing for long periods. He reported that the pain was worse when ascending or descending stairs, and when walking on uneven ground. On examination, no swelling was found, and a protrusion on the right lateral knee was noted. The examiner also noted the presence of pain on manipulation of the knee, and some popping on bending of the knee. Range of motion testing revealed extension to zero degrees, and flexion to 45 degrees. The examiner diagnosed traumatic injury of the right knee. A few months later, in May 1996, the veteran underwent a new VA joints examination. At that time, the veteran complained of chronic pain in the right knee, which became worse upon ambulation for any distance. He also complained of swelling and locking of the knee. On examination, the examiner again noted the bony protrusion to the right lateral knee, as well as slight swelling to the right medial knee area. Range of motion testing revealed extension to zero degrees, and flexion to 90 degrees. The examiner also found gross crepitus and popping with tenderness to the right lateral knee with any range of motion of the knee. However, the examiner stated that there was no subluxation or lateral instability, malunion, or non-union of the knee. The examiner diagnosed osteocartilaginous extoses and degenerative osteoarthrosis of the right knee. In June 1996, the veteran testified at a Travel Board hearing before a Board Member. At that time, he stated that he suffered from constant, aching right knee pain, which was worse following activity. He stated that his knee swelled approximately once per month, and was unstable, occasionally locking or giving out. He also stated that he wore a knee brace to help with his knee problems and to provide support. Most recently, the veteran underwent a VA examination in May 1998. At that time, the veteran again complained of chronic right knee pain, exacerbated when using stairs. He also reported continued swelling, giving way, and catching of the knee, and stated that he relied to a considerable extent on his knee brace for ambulation. On examination, the veteran's right knee showed a fixed flexion deformity. There was marked crepitation on bending. The patella could not be subluxated. There was a small amount of right knee effusion, and discomfort upon compression of the patella. The stability of the knee was intact, with no Lachman's sign. However, there was considerable anterior Drawer sign. There was no instability on varus and valgus testing at 30 degrees. The examiner also noted profound medial and lateral joint line tenderness, along with some effusion. McMurray's test was difficult to evaluate, but clearly produced marked discomfort. There was no pivot shift, and Apley test was markedly abnormal. Range of motion testing revealed extension to 8 degrees, and flexion to 110 degrees, with marked crepitation. The veteran's extension was noted to be limited by a rigid fixed structural deformity in the knee. The examiner diagnosed marked three-compartment osteoarthritis in the right knee, which resulted from the veteran's earlier meniscectomy in 1968. The examiner further stated that the veteran's persistent osteoarthritis in one knee compartment had led to degeneration of the entire knee, and he therefore recommended a right total knee arthroplasty. The veteran's right knee disorder has been rated as 20 percent disabling under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257. Pursuant to this code section, a 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability of the knee. A 30 percent rating is warranted when the evidence shows severe subluxation or lateral instability. A review of the evidence detailed above reveals that the veteran has not been found to suffer from significant right knee subluxation or lateral instability on recent examinations. Indeed, the veteran was specifically found not to suffer from either manifestation at the time of VA examinations in May 1996 and May 1998. However, the Board notes that the veteran was found to suffer from some right knee instability at the time of examination in June 1995, and wears a hinged support brace on the knee to aid in stability. He has also testified and repeatedly complained to examiners that his knee "gives out" unexpectedly, and is unstable. Finally, the Board also notes that the veteran's right knee disorder has progressed to the point where a total right knee replacement has been medically recommended. Therefore, despite the lack of evidence of moderate subluxation or instability, the Board finds that the severity of veteran's right knee disorder more closely approximates the level of severity contemplated by a 20 percent rating under DC 5257. However, given the lack of significant clinical findings of subluxation or instability, as well as the fact that some of the veteran's symptomatology has been attributed to his multi-compartment arthritis of the right knee, which is separately rated, the Board finds that the veteran's right knee symptomatology does not meet the criteria for a 30 percent rating under DC 5257. The Board has also considered whether the veteran is entitled to a higher rating under the provisions of other, related code sections which do not specifically contemplate limitation of motion of the knee. Limitation of motion of the veteran's knee is considered in the rating for traumatic arthritis as set forth below. See 38 C.F.R. § 4.14 (1999). However, the veteran has specifically been found not to have nonunion or malunion of the tibia and fibula, as contemplated by DC 5262. Therefore, an evaluation under this code would not result in a higher disability rating. II. Traumatic arthritis of the right knee The only recent evidence which indicates diagnoses of right knee arthritis includes the reports of VA examinations conducted in May 1996 and in May 1998. As noted above, in May 1996 the examiner found the veteran's right knee motion to range from zero to 90 degrees, and in May 1998 it ranged from 8 to 110 degrees. The Board notes that on both occasions, the veteran's arthritis was confirmed by radiographic findings. The veteran's traumatic arthritis of the right knee has been evaluated as 20 percent disabling under the provisions of 38 C.F.R. § 4.71a, DC 5010. DC 5010 states that traumatic arthritis is to be rated as degenerative arthritis under DC 5003. DC 5003, in turn, states that the severity of degenerative arthritis, established by x-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. The severity of limitation of knee flexion is evaluated under DC 5260. Under this code, a 20 percent rating is warranted if knee flexion is limited to 30 degrees. A 30 percent rating is warranted when knee flexion is limited to 15 degrees. In this case, the veteran's flexion has ranged from 90 degrees to 110 degrees. As both numbers are well in excess of 15 degrees, a 30 percent rating is not warranted under this code. The severity of limitation of knee extension is evaluated under DC 5261. Under this code, a 20 percent rating is warranted if knee flexion is limited to 15 degrees. A 30 percent rating is warranted if knee flexion is limited to 20 degrees. A 40 percent rating is warranted if knee flexion is limited to 30 degrees. Finally, a 60 percent rating is warranted if knee flexion is limited to 45 degrees. In this case, the veteran's extension has ranged from full (zero degrees) to 8 degrees. As the degree of limitation of extension falls far short of the 20 degrees of limitation required for the assignment of a 30 percent rating, a higher evaluation is not warranted under this code. The Board further notes that, based on these criteria, the range of motion findings for veteran's right knee do not even meet the criteria for a 20 percent rating under either DC 5260 or 5261. However, the veteran has provided extensive testimony, which the Board finds credible, as to the ways in which the pain and decreased range of motion of his right knee have made the normal tasks of everyday living difficult. Specifically, the veteran has complained of constant aching pain and swelling of the right knee, which makes everyday tasks such as walking up and down steps difficult, as well as a popping sensation when walking, especially on uneven ground or when walking downhill. In this regard, the Board notes that while lay witnesses are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Furthermore, many of these complaints, to include pain on motion, swelling, grinding, and popping, have been objectively confirmed upon medical examination. Such symptoms would undoubtedly result in some functional loss in addition to that which has objectively been demonstrated on examinations, and which the Board must consider. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The Board therefore determines that the objective evidence of a slightly limited range right knee motion, when viewed in conjunction with the veteran's hearing testimony and consistent complaints of constant aching pain on use, swelling, and popping in the right knee, which the Board finds credible, establishes that the veteran's right knee disorder more closely approximates the level of severity contemplated by a 20 percent rating under DC 5010-5261. III. Conclusion The Board would point out that its denial of each of the instant claims is based solely upon the provisions of the VA's Schedule for Rating Disabilities. In Floyd v. Brown, 9 Vet. App. 88, 96 (1996), the Court held that the Board does not have jurisdiction to assign an extra-schedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1) (1999) in the first instance. In this appeal, however, there has been no assertion or showing that the disabilities under consideration have caused marked interference with employment (i.e., beyond that contemplated in the assigned two separate 20 percent ratings for the right knee disability) or necessitated frequent periods of hospitalization so as to render the schedular standards inadequate and to warrant assignment of an extra-schedular evaluation. In the absence of such factors, the Board is not required to remand these matters to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A rating in excess of 20 percent for residuals of right knee injury, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma, is denied. A rating in excess of 20 percent for traumatic arthritis of the right knee is denied. R. F. WILLIAMS ALAN S. PEEVY Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals S. L. KENNEDY Member, Board of Veterans' Appeals Citation Nr: 9835887 Decision Date: 12/07/98 Archive Date: 12/15/98 DOCKET NO. 94-14 935A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to an increased rating for residuals of right knee traumatic arthritis, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The veteran served on active duty from July 1966 until May 1968. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans’ Appeals (Board) from a rating decision of March 1994 from the Louisville, Kentucky Regional Office (RO) which allowed a 20 percent disability rating for the service-connected right knee disorder but denied a higher evaluation in this regard. That rating determination also established service connection for PTSD, for which the veteran is currently in receipt of a 50 percent disability evaluation. This case was previously remanded by decisions of the Board dated in June 1997 and December 1997, and is once again before the signatory Member for appropriate disposition. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that the symptoms associated with his service-connected PTSD include a need for isolation from friends and family, loss of control of his temper, work difficulties, and nightmares and intrusive thoughts about Vietnam for which a higher disability rating is warranted. He also asserts that the service-connected right knee disability is manifested by locking, loss of motion, pain on movement, and frequent swelling, and is more severely disabling than reflected by the currently assigned disability evaluation. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for a higher rating for PTSD. However, with resolution of doubt in favor of the appellant, it is found that the record supports a 30 percent disability evaluation for residuals of right knee traumatic arthritis, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma, FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant’s appeal has been obtained by the RO. 2. PTSD is manifested by symptoms which include flashbacks, nightmares, anxiety, depression and social isolation productive of no more than considerable impairment of social and industrial functioning with reduced reliability and productivity. 3. Residuals of right knee traumatic arthritis, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma are manifested by findings which include extensive degenerative changes, chronic pain, limitation of motion, tenderness and effusion which are more nearly consistent with severe impairment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (1998), 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). 2. Residuals of right knee traumatic arthritis, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma are 30 percent disabling according to the schedular criteria. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5003-5010, 5257-5261 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board finds that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). A well-grounded claim is one that is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Here, the veteran's claims are well grounded because he has service-connected disabilities and evidence is of record that he claims shows exacerbation of those disorders. See Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992). The Board finds that all relevant facts have been properly developed and that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Post-Traumatic Stress Disorder Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The history of a disability must be considered. See 38 C.F.R. §§ 4.1, 4.2 (1997). However, where entitlement to compensation has already been established and an increase in a disability rating is at issue as in the instant case, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet.App. 55, 58 (1994). The Board notes in this regard that the regulations pertaining to mental disorders for VA benefits purposes were changed after the veteran filed his claim. Thus, the Board is obligated to analyze both sets of regulations and to evaluate the veteran's claim under the one most favorable to him. Karnas v. Derwinski, 1 Vet.App. 308, 313 (1990). The veteran was provided the amended regulations by the RO in evaluating his disability in the January 1997 Supplemental Statement of the Case. Prior to November 7, 1996, the regulations provided that a 50 percent rating was warranted when the ability to establish or maintain effective or favorable relationships with people was “considerably” impaired and by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels were so reduced as to result in “considerable” industrial impairment." A 70 percent rating was warranted when the above-mentioned impairment was "severe." A 100 percent rating was warranted for totally incapacitating psychoneurotic symptoms, virtual isolation in the community, or the veteran was demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132 (1996). Effective November 7, 1996, the regulations provide that a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; 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 inability to establish and maintain effective relationships. A 100 percent evaluation requires 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; and memory loss or names of close relatives, own occupation, or own name. Factual background The veteran was afforded a VA psychiatric examination for compensation and pension purposes in October 1993 whereupon he related personal and social history, including experiences he perceived as traumatic in Vietnam. He described current symptoms to include erratic sleep, dreams of being overseas, flashbacks, and disappointment and disloyalty in himself. He indicated that he had experienced a problem with alcohol. Following mental status evaluation, it was determined that he had a dysthymic disorder and PTSD which were mild in degree, and that there was also mild alcohol abuse, based on history. By rating action dated March 1994, service connection for PTSD was granted and a 10 percent disability rating was assigned, effective from May 14, 1993, the date of receipt of the claim. A treatment progress report dated in May 1995 was received from the Kelly Psychiatric Clinic which noted that the appellant had initially been a self referral who described ongoing Vietnam-related difficulties including nightmares and flashbacks, feelings of depression, anger, and concentration and attention impairment. It was reported that he remained preoccupied with his Vietnam experiences and was suffering from significant social and industrial impairment despite the fact that he continued in a full-time occupational role. It was noted that he had used alcohol in an attempt to self- medicate over the years, and that his drinking had increased The veteran was afforded a VA examination in July 1995 for PTSD purposes whereupon he elaborated upon background history and again recounted stressful experiences in Vietnam. He indicated that he felt lost after his return from service and unable to “fit in.” He related that he had worked as a coal miner since 1973, and was currently in a position which required him to scoop coal from the walls of the mine. The veteran stated that since returning from Vietnam, he had preferred not to be around people, even on his job. He said he disliked having company or going places in a group. He related that he irritated his wife because he quickly wanted to leave places they went to, and that this had impacted his social life. The appellant indicated that he was frequently annoyed, was jumpy and had tremors, and felt tense and angry. He said that he had nightmares and flashbacks two to three times a week, particularly when he heard that the United States was engaged in an armed conflict somewhere overseas. He related that he continued to have trouble sleeping and described startle response. Upon mental status examination, the veteran was observed to be well-oriented, verbal and coherent. He showed no signs of loosening of associations, or pressure of speech, although it was noted that when he began to talk of combat events, he began to speak more rapidly and became more emotionally charged. There was no sign of aphasia, or memory problems of a type that suggested organicity. No gross cognitive impairment was apparent. Mood was of great seriousness and tension. His face was noted to be strained when he spoke about his combat experiences. The examiner observed that the veteran had a mild tremor in his hands when be began to become somewhat anxious, and came close to tears as he talked about certain events. There were no signs of a psychosis or a severe mood disorder. Following mental status examination, a diagnosis of PTSD, chronic was rendered. A current General Assessment of Functioning (GAF) score of 51 was rendered. A number of lengthy statements were received from members of the veteran’s immediate family in July 1996 attesting to the severe changes in his emotional, mental and social wellbeing, as well as an inability to get on with his life following his Vietnam experience and return from service, despite medication and therapy. The veteran and his wife testified upon personal hearing on appeal before a Member of the Board sitting at Louisville, Kentucky in June 1996. Testimony was presented to the effect that he was employed in a coal mine but missed work frequently. It was reported that he said that he did not like to be around his supervisor, did not have friends or a social life, and belonged to no organizations. It was noted that he would “fly off the handle” all the time, that he had a preoccupation with guns on account of Vietnam, and was unable to engage in any pastime pursuits. The veteran’s wife related that they had been married 27 years and that he had left her in places because he was so preoccupied or his memory was so bad that he had forgotten she was with him. Received at the hearing was a treatment report dated in May 1996 from the Kelley Psychiatric Clinic noting that the appellant continued to be preoccupied with PTSD symptoms. By rating action dated in September 1996, the 10 percent evaluation for PTSD was increased to 30 percent disabling from the date of the claim received in May 1993. A treatment report from the Kelley Psychiatric Clinic dated in March 1997 was received in April 1997 essentially noting that the appellant’s psychological status had remained essentially unchanged, but there were indications of a slight diminution in his condition. He had not kept several of his appointments. Pursuant to Board remand of December 1997, the veteran underwent VA psychological examination in May 1998. The examiner noted that the claims folder was reviewed. The appellant indicated that he continued to be employed full- time in a coal mine and had operated a digger since 1990. It was reported that this type of work was solitary in nature with no contact with other employees. The veteran said that he attended church once per month and made an effort to go because this was the only place he could see his daughter. He related that he had difficulty with holidays and social activities. It was noted that he clearly avoided crowds and acknowledged difficulty controlling his temper. He said that his relationship with his wife depended on how he felt at the moment. The veteran indicated that he still consumed alcohol but on an infrequent basis. It was noted that his primary complaints were intrusive thoughts of Vietnam and an inability to get it out of his mind. Upon mental status examination, he was observed to move frequently in his chair and became easily agitated depending on the topic. He appeared anxious and depressed. He became emotional recounting combat experiences. There was no current evidence of suicidal ideation, delusions, hallucinations, or alterations in reality testing. It was noted that he was clearly oriented, but that immediate recall seemed to be impaired. It was observed that he made four errors in performing serial sevens and became somewhat irritated at himself because of his inability to complete that aspect of the examination. Following mental status examination, a pertinent diagnosis of PTSD, chronic, severe, was rendered. The GAF score was determined to be 45. The examiner further commented that the current GAF score reflected serious limitations for functional capacity and social facility. It was also found that his work actually kept his mind focused to some degree, and that alcohol did not appear to be contributing [to psychological decompensation] at present. By rating action dated in August 1998, the 30 percent disability evaluation in effect for PTSD was increased to 50 percent, effective April 18, 1997. However, as the veteran is presumed to be seeking the highest possible rating for his service-connected disability, the issue remains in controversy and appellate review must continue. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Analysis A careful review of the extensive evidence which has been generated since the inception of the instant appeal in 1993 indicates that the veteran was determined to have no more than mild psychiatric symptoms on VA examination in October 1993. However, subsequent private and VA clinical data show increasing symptomatology to include flashbacks and nightmares impacting on social and industrial functioning such that a higher rating to 30 percent was deemed warranted. The record reflects that a clinical report from the Kelly Psychiatric Clinic was received on April 18, 1997, indicating that there had been some decline in the veteran’s psychological functioning. VA examination results of May 1998 culminated in a finding of a lowered GAF score owing to psychiatric disability and a 50 percent disability evaluation was subsequently assigned. Prior to that time, however, the clinical findings on the whole clearly did not corroborate psychiatric findings of such extent so as to find that a 50 percent disability evaluation was in order. The current clinical record reflects that the appellant complains of an inability to achieve sustained sleep, as well as flashbacks, nightmares and anger. Anxiety, depression and a sense of disappointment about the future are reported. It appears that social relations on the whole are attenuated. Although the veteran contends that the symptoms associated with his service-connected PTSD are more severely disabling than reflected by the currently assigned disability evaluation, the Board finds that the evidence of record does not support this assessment. As indicated above, the evidence indicates that the findings on VA examinations in July 1995 and May 1998 attest to a significant degree of social and occupational dysfunction due to the appellant’s PTSD symptomatology. His PTSD was determined to be chronic and severe on the latter occasion. A comprehensive overview of the entire disability picture reveals that while the most recent GAF score of 45 indicates that there is indeed serious impairment in social and occupational functioning; it is demonstrated that the appellant manages to cope to a substantial extent. He is shown to have had long-term full-time employment that continues, and is in a position that allows him to work in relative isolation. He interacts with the public by going to church occasionally despite an aversion to crowds and groups. It appears that his immediate family is important to him and he maintains good relations with them. The record indicates that his marriage is of long duration and stable. It is not demonstrated that there is any history of any significant legal problems. The clinical record also discloses that no other untoward psychiatric symptomatology that the Board concludes is productive of more than “considerable” social and industrial impairment for which a 50 percent disability evaluation is warranted. It is not demonstrated that social and industrial impairment is so substantial as to reach the level of “severe” for him to be entitled to a 70 percent disability evaluation in this regard. Consequently, the Board is of the opinion that the current psychiatric findings on the whole do not more nearly approximate the criteria for a 70 percent disability rating under the regulations in effect prior to November 7, 1996. In regard to the current regulations pertaining to psychiatric disability, the Board finds no thought, or judgment impairment attributable solely to PTSD or other symptomatology associated with a 70 percent rating. As well, the veteran denies suicidal ideation, and there are no indications of obsessional rituals that interfere with routine activities, illogical speech, panic attacks, impaired impulse control, spatial disorientation, and neglect of personal appearance and hygiene. Although the veteran does have depression, anxiety, some immediate memory impairment and other manifestations, as well as deficiencies in areas such as work, social and family relations which result in some inability to establish and maintain effective relationships, these are also contemplated by the 50 percent rating under the current regulations. The Board finds that no more than a 50 percent disability evaluation for PTSD is warranted under the circumstances. Consideration has been given to the potential application of the various provisions of 38 C.F.R. Part 4, whether or not they were raised by the appellant with respect to the claim above. See generally Schafrath v. Derwinski, 1 Vet.App. 589 (1991). However, the Board finds that those sections do not provide a basis upon which to assign a higher disability evaluation as to this matter. The Board is required to address the issue of entitlement to an extraschedular rating under 38 C.F.R. § 3.321 only in cases where the issue is expressly raised by the claimant or the record before the Board contains evidence of “exceptional or unusual” circumstances indicating that the rating schedule may be inadequate to compensate for the average impairment of earning capacity due to the disability. See VA O.G.C. Prec. Op. 6-96 (August 16, 1996). In this case, consideration of an extraschedular rating has not been expressly raised. Further, the record before the Board does not contain evidence of “exceptional or unusual” circumstances that would preclude the use of the regular rating schedule. The Board has considered the doctrine of benefit of the doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Therefore, a reasonable basis for a grant of the benefit sought on appeal is not identified at this time. Right knee disability. The veteran was granted service connection for torn medial cartilage of the right knee with osteoma of the right tibia and osteochondroma of the right fibula effective May 3, 1968, whereupon a 20 percent disability evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5257. Following VA examination in October 1969, the RO reduced the 20 percent disability evaluation to a noncompensable evaluation for the right knee. A request to reopen his claim for a higher rating for the service-connected right knee was received in April 1991. In October 1991, he was assigned a 10 percent disability evaluation for the right knee. The veteran expressed dissatisfaction with the 10 percent rating for the right knee in May 1993, subsequent to which a 20 percent disability evaluation was granted by rating action dated in March 1994, effective May 14, 1993. The appeal continues pursuant to the holding in AB v. Brown, 6 Vet. App. 35, 38 (1993) which presumes that the appellant is seeking the highest possible rating for his service-connected disability. The veteran’s right knee disability is currently assigned a 20 percent evaluation under the provisions of to 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5257. These criteria provide that moderate impairment of the knee, manifested by recurrent subluxation or lateral instability, warrants a 20 percent evaluation. A 30 percent evaluation requires severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. These 10 percent evaluations are combined, not added, under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The veteran complained of pain and swelling of the right knee upon VA examination in October 1993. He indicated that it was particularly affected by cold weather and said he had to have it aspirated periodically. He related that he could only walk only one block on a flat surface without having knee pain. Examination at that time disclosed an unstable right knee with a positive Drawer’s sign. There was no swelling or deformity. Flexion was to 140 degrees and extension was zero degrees. By rating action dated in March 1994, the right knee disability evaluation was increased to 20 percent, effective May 14, 1993. The appellant was afforded a VA orthopedic examination in June 1995, and related that he was having knee pain and said that there was a large knot on the lateral side of the knee. He indicated that he had stiffness in the evenings after being on the knee all day, and said that walking on unstable ground caused tingling and pinprick sensations in the entire knee. The veteran reported that when he walked down a hill, it felt as if his knee were going to give way. He said he had severe pain when walking on any kind of incline. The veteran was observed to walk with a limp. He wore a hinged support brace on the right knee. Examination disclosed some swelling and deformity of the knee. The right knee measured 37 centimeters as compared to 36 on the left. There was instability of the right knee and a positive Drawer’s sign. Pain was elicited on the medial and lateral aspects of the right knee to touch. Flexion was to 90 degrees and extension was to zero. X-ray studies noted oateoarthrosis with marginal spurring. The veteran underwent a VA examination of the joints in February 1996 and related that he had been told by his private physician the previous year that he needed a total right knee replacement. He continued to complain of pain, swelling and stiffness, especially upon use, and indicated that he had locking upon exertion. No swelling was observed upon examination but deformity was noted. Flexion was to 45 degrees and extension was zero. On VA orthopedic examination in May 1996, the veteran complained of chronic pain that increased with ambulating any distance. He stated that he continued to have symptoms of swelling and locking. Flexion of the right knee was to 90 degrees and extension was to zero. No swelling was noted. No subluxation, lateral instability, nonunion with loose motion or malunion was noted. The veteran presented testimony upon personal hearing on appeal in June 1996 to the effect that he had increasing right knee instability and swelling as well as chronic pain that hampered his work activities. Pursuant to Board remand of June 1997, the appellant was afforded a VA joints examination in May 1998. It was noted on this occasion that he had exhibited progressively advancing osteoarthritis of the right knee over the years and had been treated by a variety of modalities including physical therapy, intermittent bracing, Cortisone injections, nonsteroidals and analgesics. It was reported that the veteran currently complained of chronic pain that was particularly exacerbated by climbing or even descending stairs. He stated that there were also symptoms of intermittent swelling, and giving way and catching that occurred several times a week, particularly upon rising from a chair. The veteran was observed to rely to a considerable extent on a right knee brace for ambulation. He was not currently using a cane. The examiner noted that physical examination was striking for a fixed flexion deformity of the right knee. It was noted that the veteran lacked eight degrees of full extension. Flexion was to approximately 110 degrees and was accompanied by marked crepitation. The patella could not be subluxated nor did it balotte. A small right knee effusion was observed. There was discomfort upon compression of the patella against the trochlear groove. There was a 12 centimeter scar of the right knee that was well-healed. It was noted that the scar was not tender but that the underlying medial and joint line exhibited profound tenderness. The stability of the right knee was intact. Palpation of the knee disclosed no significant temperature increase. It was noted that the veteran experienced difficulty squatting and climbing onto and off the examining table. The examiner stated that the McMurray’s test was difficult to test in that setting, but that it clearly produced marked discomfort. The Apley test was markedly abnormal. There was no pivot shift. Radiological study of the right knee revealed significant three-compartment osteoarthritis which was more pronounced in the medial compartment. The posture of the knee on radiograph was varus with virtual obliteration of the medial cartilage space. There was significant sclerosis throughout the knee, along with moderate osteophytosis, especially of the medial compartment. It was noted that an incidental finding which was unrelated to the veteran’s pathology was the presence of an osteochondroma of the proximal tibia. In comments following the examination, the examiner stated that loss of the veteran’s meniscus directly resulted in medial compartment osteoarthritis. It was found that radiographic and clinical findings were consistent with a diagnosis of extensive osteoarthritis of the right knee. It was determined that the effect of persistent osteoarthritis had led to degeneration of the entire knee which would best be treated by total knee arthroplasty, and that the appellant was a candidate for such at a premature age. The evidence in this instance clearly demonstrates a progression of right knee residuals over the years, particularly degenerative changes, leading to chronic symptomatology including pain, marked crepitation, deformity, effusion, tenderness and limitation of motion. The veteran has indicated that his private physician has told him that he is a candidate for total knee replacement and this was corroborated on most recent VA examination. The Board finds that with consideration of 38 C.F.R. §§ 4.40, 4.45 and 4.59, as well as upon review of the nature of the disability and the functional impairment which can be attributed to pain, weakness, and fatigability, the evidence supports the assignment of a 30 disability evaluation for the service- connected right knee disorder. See DeLuca. The benefit of the doubt is thus resolved in favor of the veteran as to this matter by finding that a 30 percent disability evaluation is warranted for the service-connected right knee disability. However, absent a finding of more substantial impairment, to include more substantial limitation of motion, lateral instability, recurrent subluxation, ankylosis, or other objectively manifested pathology indicative of a more severe disability picture, an evaluation in excess of 30 percent is not warranted. Finally, the Board notes that radiographic reports show degenerative changes of the knee. Degenerative arthritis, Code 5003, is rated based on limitation of motion of the affected joint under the appropriate diagnostic code. In a recent precedent opinion, VA’s Office of General Counsel (OGC) held that a veteran who has arthritis and instability of the knee may be rated separately under Code 5003 and Code 5257. VAOPGCPREC 23-97. See VAOPGCPREC 9-98 (if a musculoskeletal disability is rated under a diagnostic code that does not involve limitation of motion, and another diagnostic code based on limitation of motion may be applicable, the latter diagnostic code must be considered in light of 38 C.F.R. §§ 4.40, 4.45, and 4.59); Johnson, supra, (Code 5257 did not involve limitation of motion). However, a separate rating can be established only if the disability meets the criteria for at least a 0 percent rating under either diagnostic code for limitation of motion. Id.; VAOPGCPREC 9-98. Under Code 5260, a 0 percent rating is assigned when leg flexion is limited to 60 degrees. Under Code 5261, a 0 percent rating is assigned when leg extension is limited to 5 degrees. As stated above, the right knee flexion was to 110 degrees and extension was limited by 8 degrees during the May 1998 VA examination These results do not meet the criteria for the 0 percent ratings under Code 5260 or Code 5261. Therefore, a separate rating for arthritis and limitation of motion under Code 5003 is not in order. ORDER An increased rating for PTSD is denied. An increased rating to 30 percent for residuals of right knee traumatic arthritis, status post meniscectomy, anterior cruciate ligament (ACL) instability and right tibial osteoma is granted subject to controlling regulations governing the payment of monetary awards. RENÉE M. PELLETIER Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -