Citation Nr: 1703874 Decision Date: 02/08/17 Archive Date: 02/23/17 DOCKET NO. 10-41 503 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for sleep apnea, claimed as secondary to posttraumatic stress disorder (PTSD). 2. Entitlement to an initial disability rating in excess of 30 percent for PTSD. 3. Entitlement to a rating in excess of 20 percent for diabetes mellitus. 4. Entitlement to a separate compensable rating for bilateral cataract. 5. Entitlement to a rating in excess of 10 percent for peripheral neuropathy with sural paresthesia and plantar fasciitis of the left lower extremity. 6. Entitlement to a rating in excess of 10 percent for peripheral neuropathy with sural paresthesia and plantar fasciitis of the right lower extremity. 7. Entitlement to a compensable rating for right fifth metacarpal fracture. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran had honorable active duty service from September 1958 to June 1981. These matters come to the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, denied service connection for sleep apnea; granted service connection for PTSD and assigned a 30 percent rating effective October 16, 2008; and continued ratings assigned for diabetes mellitus with bilateral cataract, peripheral neuropathy of both lower extremities, and right fifth metacarpal fracture. The Veteran requested a Board hearing in his October 2010 VA Form 9. This request was subsequently withdrawn in August 2014. The claims were remanded by the Board in July 2015 for additional development. At that time, the issue of entitlement to a compensable rating for bilateral cataract was separated from the diabetes mellitus. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The competent and probative evidence of record does not establish that the Veteran's sleep apnea had its onset in service, is causally related to service, or was caused or aggravated by the Veteran's service-connected PTSD. 2. The Veteran's PTSD has not caused occupational and social impairment with reduced reliability and productivity at any time during the appeal period. 3. The Veteran's diabetes mellitus does not require regulation of activities. 4. The Veteran's bilateral cataracts are manifested by corrected vision better than 20/40 in both eyes. 5. The Veteran does not exhibit more than mild incomplete paralysis of the sciatic nerve in either lower extremity. 6. The Veteran's right fifth metacarpal fracture is not manifested by ankylosis of both the metacarpophalangeal and proximal interphalangeal joints and does not result in limitation of motion of other digits or interfere with overall function of the hand. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2016). 2. The criteria for an initial disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2016). 3. The criteria for a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2016). 4. The criteria for a separate compensable rating for bilateral cataracts have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.84a, Diagnostic Code 6028 (2007). 5. The criteria for a rating in excess of 10 percent for peripheral neuropathy with sural paresthesia and plantar fasciitis of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2016). 6. The criteria for a rating in excess of 10 percent for peripheral neuropathy with sural paresthesia and plantar fasciitis of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2016). 7. The criteria for a compensable rating for right fifth metacarpal fracture have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5156, 5227 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. VA's duty to notify was satisfied by a letter in November 2008 and June 2009. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In regards to the claim for an initial rating in excess of 30 percent for PTSD, the Veteran's increased rating claim arises from his disagreement with the initial evaluation that was assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) ((section 5103(a) notice is no longer required after service-connection is awarded). In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. VA examinations have been conducted and opinions obtained. The Board also notes that actions requested in the prior remand have been undertaken. More specifically, the Veteran was asked to provide the names, addresses and approximate dates of treatment of all health care providers who had recently treated him for his claimed disabilities, to include any Vet Center where he was attended group therapy; VA medical records were obtained; and VA examinations were obtained in conjunction with the claims for sleep apnea, PTSD, and peripheral neuropathy. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2016). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease or injury. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran essentially contends that he developed sleep apnea as a result of his service-connected PTSD. In a July 2011 statement, he reported that he was told by a doctor that his PTSD was the cause of his stopped breathing at night. Although he has not claimed sleep apnea is related to his active duty service, the Board will also consider the Veteran's claim on a direct basis. As an initial matter, the Board notes that the Veteran has been diagnosed during the course of the appeal with obstructive sleep apnea. Accordingly, the first criterion for establishing service connection has been met. The question becomes whether this condition is related to service or to his service-connected PTSD. Service treatment records are devoid of reference to complaint of, or treatment for, any symptoms suggestive of a sleep disorder or of trouble sleeping. At the time of the Veteran's February 1981 retirement, he denied frequent trouble sleeping and clinical evaluation of all pertinent systems was normal. See report of medical history and examination. The Veteran underwent a VA sleep medicine consult in December 2008, at which time he reported that his spouse said he snored heroically and had witnessed apnea and at which time he reported he occasionally would wake up choking. The impression indicated that clinical findings and physical exam strongly indicated sleep disordered breathing as well as sleep maintenance insomnia. A fee basis sleep study was requested. A January 2009 VA sleep medicine note indicates that the Veteran was notified by telephone of his sleep study results, which diagnosed mild sleep apnea. Obstructive sleep apnea was diagnosed during a December 2015 private sleep study report. The Veteran underwent a VA sleep apnea Disability Benefits Questionnaire (DBQ) in February 2016, at which time he was diagnosed with obstructive sleep apnea. The examiner noted that an October 2015 VA pulmonology note reported that the Veteran had a history of obstructive sleep apnea treated with CPAP since a 2009 sleep study; that the Veteran was advised to have a new sleep study to determine the type of parasomnia, but he declined; and that the provider opined that the Veteran's sleep disorders may be related to PTSD. At the time of the February 2016 VA examination, the Veteran reported that his new sleep mask, prescribed six or seven months prior, was excellent and that he was snoring less and sleeping well. The examiner also noted that the Veteran had obstructive sleep apnea and mental health related sleep issues according to VA providers. It was the examiner's opinion that the Veteran's obstructive sleep apnea was entirely separate and distinct from PTSD and mental health related sleep disorders such as may cause the Veteran's parasomnias and nightmares. The examiner explained that there is no evidence whatsoever that PTSD causes or aggravates obstructive sleep apnea; however, advancing age and obesity are known risk factors. The examiner noted that the Veteran was diagnosed with obstructive sleep apnea in 2009 at the age of 70 years, and his BMI recently exceeded 34, making him obese. In other words, various sleep difficulties are known to be statistically more common in PTSD patients, and there are a variety of sleep disorders found in these patients, but these should not be confused with obstructive sleep apnea. Notwithstanding the comment in the VA record by providers, PTSD is not a cause of obstructive sleep apnea and has no logical contribution to make for aggravation of obstructive sleep apnea. The preponderance of the evidence of record is against the claim for service connection for sleep apnea on a direct basis. This is so because service treatment records do not indicate the Veteran sought treatment for any complaints related to a sleep disorder, to include sleep apnea, and the Veteran denied trouble sleeping at the time of his 1981 retirement examination. Moreover, there is no indication that the Veteran was treated for complaints related to sleep apnea prior to December 2008, which is approximately 27 years after his discharge from active duty service, and no evidence linking his diagnosed sleep apnea to service. The preponderance of the evidence of record also is against the claim for service connection for sleep apnea on a secondary basis. The Board acknowledges the Veteran's assertion that he was told by a doctor that his PTSD was the cause of his stopped breathing at night, as well as the October 2015 VA pulmonology note that included the provider's opinion that the Veteran's sleep disorders may be related to PTSD. However, the pulmonology note provides, at best, a speculative opinion and is of little, if any, probative value. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (holding doctor's statement that veteran's brain tumor "may well be" connected to Agent Orange exposure was speculative); see also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that medical opinions are speculative and of little or no probative value when a physician makes equivocal findings such as "the veteran's death may or may not have been averted"). Conversely, the examiner who conducted the February 2016 DBQ provided an opinion that the Veteran's obstructive sleep apnea was entirely separate and distinct from PTSD. This opinion, which was based on a detailed rationale, namely that that there is no evidence that PTSD causes or aggravates obstructive sleep apnea, but that advancing age and obesity, both factors in the Veteran's case, are known risk factors, is afforded high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). While the Veteran believes that his current sleep apnea is related to his service-connected PTSD, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of sleep apnea are matters not capable of lay observation, and require medical expertise to determine. Accordingly, his opinion as to the diagnosis or etiology of his sleep apnea is not competent medical evidence. The Board finds the opinion of the February 2016 VA examiner to be significantly more probative than the Veteran's lay assertions. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107 (b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2016); see also 38 C.F.R. §§ 4.45, 4.59 (2016). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Once a particular joint is evaluated at the maximum level in terms of limitation of motion, there can be no additional disability due to pain. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Entitlement to an initial disability rating in excess of 30 percent for PTSD Service connection for PTSD was granted in the November 2009 rating decision that is the subject of this appeal. An initial rating of 30 percent was assigned pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Pursuant to the General Rating Formula for Mental Disorders, a 30 percent evaluation is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2016). 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 understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting 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 name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994) (DSM-IV). A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score generally reflects an examiner's finding as to the Veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2016). The Veteran reports the following symptoms associated with his PTSD: impaired sleep; hyper-alertness; inability to relax; jumpiness; impaired concentration; feeling like hiding when he hears loud noises; shutting off his emotions; impaired memory; anger/rage; hypervigilance; impaired startle response; and not liking to be in crowded places. See July 2009 VA Form 21-4138. Several of the Veteran's friends have written statements regarding PTSD symptomatology. They indicate that he shows signs of stress; has outbursts of anger; hears things that remind him of past service duties; is unable to enjoy holidays with fireworks; that he seems distant at times and uninterested, as if he is in another world; that he seems uneasy and removes himself when in a large group of people; and that the Veteran has complained of lack of sleep and nightmares. See statements from A.E.B. and M.L.S. received in August 2009. The medical evidence in this case consists of VA treatment records and several VA examination reports. The Veteran underwent a VA psychology consult in December 2008. He was referred by his primary care physician for evaluation and presented with symptoms of PTSD. The Veteran reported that he had been married for 45 years and was still in love with his wife. They had four children, 14 grandchildren, and six great-grandchildren. It was noted the Veteran had left his job in October due to a rotating shift pattern being too physically taxing on him. He had decided not to return once his Family Medical Leave Act (FMLA) benefits ran out. The Veteran reported that his wife was very supportive. Presenting concerns included some nightmares at night, which had recently worsened; and increased irritability since he had stopped working. Depressive symptoms included insomnia, low energy/fatigue; and emotional lability. The Veteran denied suicidal or homicidal ideation. Anxiety symptoms included restlessness, feeling edgy, easy fatigability, irritability, muscle tension, sleep problems, gastrointestinal distress, and fear of public places and crowds. The Veteran also reported intrusive thoughts, nightmares, hypervigilance and increased startle response. He also reported insomnia and it was noted that probable sleep apnea was a possible cause. Mental status examination revealed that the Veteran was clean and casually dressed. Speech was of normal rate and rhythm, mood was euthymic, and affect was appropriate to content and of full range. Thought process was clear and coherent and there were no auditory or visual hallucinations, delusions, or assaultive thoughts. The differential diagnosis was adjustment disorder with mixed anxiety and depressed mood; some symptoms of PTSD. A GAF score of 62 was assigned. The Veteran underwent a VA psychology consult in August 2009 for evaluation of depression. He reported increased problems sleeping and intense dreams of Vietnam. He endorsed some anhedonia, irritability, problems being in crowds, increased startle response (hitting people who sneak up on him), decreased appetite and sleep disturbance. It appears mental status examination was done by phone interview. The Veteran's speech was of normal rate and tone and mood was euthymic. Thought process was goal directed and there was no evidence of a thought disorder. The Veteran denied current homicidal and suicidal ideations. An Axis I diagnosis of adjustment disorder, rule out PTSD, was made and a GAF score of 55 was assigned. The Veteran underwent a VA psychology consult in September 2009 for evaluation of PTSD symptoms. Presenting problems included awakening three to four times a night; occasional nightmares; intrusive memories; sexual issues; forgetfulness; irritability; impatience; increasing social withdrawal; few friends and reduced appetite. Mental status revealed that appearance was within normal limits and the Veteran was cooperative, friendly and open and oriented times three. The Veteran endorsed the following descriptions of his mood over the past month, namely restless, angry, agitated, jumpy, argumentative, talkative, withdrawn and hyperactive. Depression was at a level seven and anxiety was at a level eight. Cognition was within normal limits and judgment was good. The Veteran was not a danger to himself or to others. An Axis I diagnosis of PTSD was made and a GAF score of 59 was assigned. A September 2009 VA psychiatry note indicates that the Veteran was seen for medication evaluation, at which time he reported problems sleeping through the night, getting irritable with people, and getting jumpy with loud noises. He also had poor appetite, fatigue, and felt fidgety and restless. Mental status examination revealed that the Veteran was alert and oriented, lucid and composed. Thoughts were logical and coherent and there was no suicidal or homicidal ideation. Mood reflected some depression. Axis I diagnoses of anxiety disorder (features of PTSD) and depression were made and a GAF score of 60 was assigned. The Veteran underwent a VA PTSD examination in September 2009. Current psychiatric symptoms were nightmares; intrusive thoughts; flashbacks; avoidance of stimuli associated with trauma; avoidance of crowded places; difficulty falling asleep and staying asleep; concentration problems; exaggerated startle response to loud noises; hypervigilance; and irritability. Nightmares occurred two to three times a week and flashbacks occurred two to three times a month. Symptoms of avoidance and increased arousal occurred daily. The severity of each symptom was noted to be severe. The Veteran reported that nightmares ruined his whole night and that flashbacks messed him up the whole day. It was noted the Veteran had retired from his job as a supervisory corrections officer for the Texas Department of Corrections on December 30, 2008, and that he had been at this job for 33 years. He did not contend that his unemployment was due to the effects of the mental disorder. The Veteran reported that he had been married for 46 years and had four children, 15 grandchildren, and six great grandchildren. He stated, "I get along with them fine, but I won't speak to them if they make me mad." He also reported, "I have no patience. I get irritable, especially if people interrupt me or talk over me." In regards to social relationships, the Veteran reported "I don't have many friends. Maybe I can count on one hand how many friends I got. I don't like to be around people. Crowds are no good. If people sneak up on me, I knock them across the room. I don't mean to, but it just happens. I get defensive. I just get up and go. My closest friend is my wife." The Veteran indicated that he liked to fish and play with his grandchildren and that he and his wife had a lot of fun together as she knew what to do when he got upset, either leave him alone or make him laugh. He denied suicidal attempts and indicated that he throws things or throws something down if he is snuck up on. Mental status examination revealed that the Veteran had no impairment of thought process or communication; no delusions or hallucinations; and no inappropriate behavior. The Veteran had no suicidal or homicidal plans or intent. He was able to maintain minimal personal hygiene and other basic activities of daily living. The Veteran was oriented to person, place, and time and had some memory loss/impairment, which he described as mild, specifically noting he had trouble remembering people's names. The Veteran did not have any obsessive or ritualistic behavior that interfered with routine activities; any irrelevant, illogical, or obscure speech patterns; or panic attacks. The examiner also noted that the Veteran did not have depression or depressed mood, but did have daily, severe anxiety, which the Veteran described as "I get cold sweats again. My nerves are jingling. I get goose pimples. I am paranoid of what's around me. I can't be in crowds. I can't stand to hear a car backfire. Bad accidents trigger me too." The Veteran did not have impaired impulse control, but did have sleep impairment, which he described as difficulty falling asleep and staying asleep just about every night, which was moderate to severe. An Axis I diagnosis of chronic, severe PTSD was made and a GAF score of 62 was assigned. The examiner indicated there was occasional decrease in work efficiency or there are intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but generally satisfactory functioning (routine behavior, self-care, and conversation normal.) The examiner noted the Veteran's prognosis for improvement was good with treatment, including continued medication management along with individual and group therapy. An October 2009 psychiatry note indicates that the Veteran presented for re-evaluation of medications for anxiety, insomnia and symptoms of PTSD. He reported feeling no better with Trazodone and still felt tired in the morning, and possibly more moody. He denied significant depression but nightmares and frustration continued. The Veteran reported that he had a two year old great granddaughter who did not allow him to be too depressed. Mental status examination revealed that the Veteran was alert and oriented and engaged in the interview. Thoughts were logical and coherent and there was no suicidal or homicidal ideation. Mood was slightly anxious and affect was normal. An Axis I diagnosis of PTSD was made and a GAF score of 70 was assigned. VA treatment records indicate that the Veteran underwent group psychological treatment between January 2010 and March 2010 and again from September 2010 until June 2011. An October 2010 VA psychology treatment plan notes indicates that the Veteran had Axis I diagnosis of chronic PTSD and depressive disorder, not otherwise specified. A GAF score of 60 was also noted. It was noted the Veteran had reached his original treatment goal of reducing levels of distress and that he wanted to continue decreasing this. It was also noted the Veteran had completed an anger management group and continued to have problems with panic in crowds and nightmares/sleep problems. He requested enrollment in nightmare/sleep hygiene groups. A November 2010 VA physician note indicates that the Veteran was seen with complaints of PTSD symptoms. It was noted that medications had resulted in no depression or anxiety. The Veteran stated he was a little irritated at his grown middle-aged children who "dump on" his wife and do not take care of things themselves. He also reported interrupted sleep, nightmares twice a week, and occasional flashbacks. The Veteran had been married for 48 years and was living with his wife. Symptoms of PTSD reported by the Veteran included re-experiencing and hyperarousal. Mental status examination revealed that the Veteran was casually dressed and well groomed. He was cooperative and made good eye contact. He was oriented times three and his speech was of normal rate and rhythm. Mood was euthymic and affect was full. Thought process was goal directed and there was no looseness of associations or flight of ideas. The Veteran also denied auditory, visual, olfactory and tactile hallucinations as well as delusions, obsessions, illusions and paranoid ideation. He also denied suicidal ideation, intent or plan, homicidal ideation, and violence. Attention, concentration, naming, fund of information, judgment, insight and impulse control were all noted to be good and memory was intact. An Axis I diagnosis of PTSD by history was made and a GAF score of 65 was assigned. A May 2011 VA physician note indicates that the Veteran was seen with complaints of PTSD symptoms. It was noted that medical had been increased in March at his request, and the Veteran reported feeling better, less irritable, and less depressed since increase of medication. Sleep was interrupted by increased nightmares which are not military related. He was less isolated than before and the Veteran indicated that he felt he had gained an understanding of himself, triggers and his PTSD by being in treatment. It was noted he attended group therapy at VA and a Vet Center. Symptoms of PTSD reported by the Veteran included nightmares and hyperarousal. It was noted that the Veteran was living with his wife. Mental status examination revealed that the Veteran was casually dressed and well groomed. He was cooperative and made good eye contact. He was oriented times three and his speech was of normal rate and rhythm. Mood was slightly irritable and affect was full. Thought process was goal directed and there was no looseness of associations or flight of ideas. The Veteran also denied auditory, visual, olfactory and tactile hallucinations as well as delusions, obsessions, illusions and paranoid ideation. He also denied suicidal ideation, intent or plan, homicidal ideation, and violence. Attention, concentration, naming, fund of information, judgment, insight and impulse control were all noted to be good and memory was grossly intact. An Axis I diagnosis of PTSD was made and a GAF score of 60 was assigned. The Veteran underwent a review PTSD DBQ in February 2016. The current diagnosis was unspecified trauma and stressor-related disorder; the examiner explained that the Veteran had been diagnosed with PTSD in the past, but no longer met the diagnostic criteria for PTSD based on the DSM-5. There was occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran rated his average mood between a level eight and 10 and endorsed distress from nightmares about combat experiences while in Vietnam where he is fighting someone and another where he is falling over a cliff. He has ended up on the floor after this dream. He sometimes thrashes in his sleep. He said that he experiences more intrusive thoughts at night and during such time he often thinks about what he could have done differently while in Vietnam. He endorsed occasional experiences of anger and low frustration tolerance. He said, "I can't stand crowds, I don't like people bumping on me." "I don't argue with people I walk away." He explained that he lost about 20 pounds in one year without trying. His chief concerns were problems getting an erection, high blood pressure, and diabetes. The examiner reported that symptoms that actively applied to the Veteran's diagnosis included chronic sleep impairment and disturbances of motivation and mood. Behavioral observations included that the Veteran was accompanied by his wife and another female who both remained in the waiting area during his interview. He was neatly and appropriately dressed. He presented with a euthymic mood and congruent affect. He initially presented as somewhat suspicious and guarded, but he seemed to become more relaxed and forthcoming with personal information as the interview progressed. Recent and remote memory was intact. He maintained sufficient and appropriate eye contact. Thought process was logical and goal directed. Thought content was unremarkable. There were no indications of derailment or any bizarre thinking. No obvious signs of hallucinations of any kind. No apparent delusions or paranoia. Insight and judgment were intact. He was alert and oriented to person, place, time and purpose. He denied suicidal and homicidal thoughts. The Veteran was capable of managing his financial affairs. Based on the Veteran's self-report during the evaluation, the examiner determined that it did not appear that his current symptoms meet the diagnostic criteria for PTSD under DSM-5 criteria. The examiner explained that the quantity and intensity of his self-reported symptoms are minimal and are more suggestive of a diagnosis of unspecified trauma and stressor related disorder. This category applies to presentations in which symptoms characteristic of a trauma- and stressor-related disorder cause some distress in important areas of functioning but do not meet the full criteria for any of the disorders in the trauma- and stressor-related disorders diagnostic class to include PTSD. It was the examiner's opinion that the current disorder was incurred in or caused by experiences while serving in the Vietnam War. A March 2016 VA physician note indicates that the Veteran continued his medications and was living with his wife and dog. He spent his time running three, soon to be four, grandchildren around and also played with his dog. The Veteran reported working part time as a bondsman. It was noted that the Veteran was calm and cooperative; that speech was of normal rate, volume and prosody; that thought process was linear, logical and goal-oriented; that there was no suicidal or homicidal ideation, audiovisual hallucinations, or paranoid delusions; that mood was good and affect was stable; and that the Veteran's judgment, insight and motivation were guarded. The assessment was PTSD. The Veteran underwent another review PTSD DBQ in March 2016. This time, a current diagnosis of PTSD was provided. The examiner indicated it caused 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 Veteran reported that he remained married to his wife of over 50 years. There were four adult children from this marriage and the Veteran reported spending his time transporting his family. He stated that he periodically traveled to visit family members. The Veteran's wife stated that she had removed all firearms from the household due to the Veteran's irritability. The Veteran reported that he had retired in 2008 after 33 years of service in the Texas Department of Corrections Juvenile division, and had since periodically worked as a bail bondsman. Since this time, he had not sought further occupational or educational endeavors. The Veteran indicated that he was prescribed medication and had participated in group psychotherapy for PTSD and anger management. The examiner reported the following symptoms actively applied to the Veteran's diagnosis: anxiety, suspiciousness and chronic sleep impairment. Behavioral observations included that the Veteran presented for evaluation casually dressed and well groomed. He was escorted by his wife. The Veteran was alert and oriented times four. Speech was fluent. Thought processes were logical and coherent. Affect was irritated with the situation, but not the examiner. The Veteran was capable of managing his financial affairs. The evidence of record does not support the assignment of a rating in excess of 30 percent for PTSD at any time during the appeal period. As an initial matter, nine GAF scores were assigned during the time frame being considered by the Board, specifically one score of 55, one score of 59, three scores of 60, two scores of 62, one score of 65 and one score of 70. The majority of the scores represent moderate symptoms or moderate difficulty in social or occupational functioning. The Board has considered the assignment of these GAF scores in conjunction with the subjective symptoms reported by the Veteran and others who know him (many of which reflect disturbances of motivation and mood), to include impaired sleep; hyper-alertness/hypervigilance/inability to relax; jumpiness; impaired concentration; feeling like hiding when he hears loud noises; shutting off his emotions; impaired memory; irritability/anger/rage; hypervigilance; impaired startle response; not liking to be in crowded places; nightmares; intrusive thoughts/flashbacks; decreased appetite; and social withdrawal; and with the objective evidence of record as reflected in VA treatment records and the VA examination reports, to include impairment in affect. There is no evidence, however, that the Veteran's PTSD has caused occupational and social impairment with reduced reliability and productivity due to such symptoms as circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment or abstract thinking; or difficulty in establishing and maintaining effective work and social relationships at any time during the appeal period. Importantly, the Veteran's speech has consistently been described as of normal rate and rhythm or fluent; there is no indication that the Veteran has ever reported panic attacks or had difficulty understanding any commands; the Veteran's memory has consistently been described as intact on objective examination; his judgment was described as good/intact until March 2016, when it was reported as guarded; impulse control was consistently reported as good; and there is no indication that he had any impaired abstract thinking, as thought processes were reported as logical, coherent, clear, goal directed and linear, and there was no objective evidence of a thought disorder. In addition to the foregoing, the Veteran has been considered capable of managing his financial affairs Moreover, there is no indication that the Veteran has difficulty in establishing and maintaining effective social relationships. The Board acknowledges the Veteran's assertion that he has few friends. The fact remains, however, that he does have some friends, a few of which wrote statements in support of his claim, that he has remained married to the same woman for over 50 years, who he reports is his closest friend and a good support, and the Veteran has continuing interaction with his large extended family, to include spending the majority of his time transporting family and periodically traveling to visit family members. It is also noted that the Veteran reported working part time as a bondsman in March 2016 and that he has been able to attend group therapy during the appellate period. In sum, the preponderance of the evidence supports the currently assigned 30 percent rating for PTSD. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Entitlement to a rating in excess of 20 percent for diabetes mellitus Service connection for diabetes mellitus was originally granted in a May 2002 rating decision, which assigned a 20 percent rating pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913. The disability was recharacterized on several occasions, first in an October 2002 rating decision that granted service connection for sexual dysfunction and again in a July 2007 rating decision that granted service connection for bilateral cataract, both of which were determined to be noncompensable and rated in conjunction with the diabetes mellitus. In the November 2009 rating decision that is the subject of the current appeal, the rating assigned for diabetes mellitus with bilateral cataract was continued at 20 percent pursuant to Diagnostic Code 7913. In its July 2015 remand, the Board separated the bilateral cataract as its own issue; that portion of the claim will be adjudicated as distinct from the increased rating for diabetes claim in the following section. The Board notes at this juncture that service connection for erectile dysfunction was established as separate from the diabetes mellitus in an April 2013 rating decision, which granted a noncompensable rating effective October 16, 2008, and which also granted special monthly compensation for loss of use of a creative organ, also effective October 16, 2008. The April 2013 rating decision is not subject to the Board's jurisdiction. The Board also notes that the Veteran has not provided any statements in support of his contention that he is entitled to a rating in excess of 20 percent for diabetes mellitus. Diagnostic Code 7913 provides a 20 percent evaluation when diabetes mellitus contemplates the need for insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. Ratings in excess of 20 percent all require insulin, restricted diet, and regulation of activities; ratings higher than 40 percent require other criteria in addition to these. The Court of Appeals for Veterans' Claims (Court) has defined the "regulation of activities" as the "avoidance of strenuous occupational and recreational activities," and concluded that medical evidence is required to show that occupational and recreational activities have been restricted. See Camacho v. Nicholson, 21 Vet. App. 360 (2007). The medical evidence in this case consists of VA and private treatment records, as well as several VA examination reports. A December 2008 VA treatment record indicates that the Veteran's diabetes therapy included diet and oral agent. There is no indication from VA or private treatment records dated through March 2016 that the Veteran has been prescribed insulin for his diabetes. The Veteran underwent a VA diabetes mellitus examination in April 2009. He reported being on a diabetic diet but weight was stable. There had been no episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations in the past year. The Veteran did not have any restriction of activities on account of the diabetes. Treatment consisted of oral hypoglycemic (Glyburide), but not insulin. The Veteran received treatment every six months. There were no effects on occupational functioning and daily activities. The diagnosis was type II diabetes mellitus, stable on medications. The Veteran underwent a VA diabetes mellitus DBQ in March 2013. Treatment was noted to only include prescribed oral hypoglycemic agents. The Veteran did not require regulation of activities as part of medical management of diabetes mellitus and did not have progressive unintentional weight loss attributable to diabetes mellitus. There was no functional impact on the Veteran's ability to work because he was retired. The preponderance of the evidence of record is against the assignment of the next highest (40 percent) rating provided under Diagnostic Code 7913 for the service-connected diabetes mellitus. This is so because the Veteran has not asserted, and the medical evidence does not show, that his diabetes mellitus requires insulin or regulation of activities, both of which are required for the assignment of a rating in excess of 20 percent. Rather, the Veteran's diabetes mellitus appears to have only been treated by oral hypoglycemic agents and there is no indication that he has been told to regulate his activities. In sum, the preponderance of the evidence supports the currently assigned 20 percent rating for diabetes mellitus. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Entitlement to a separate compensable rating for bilateral cataracts As noted in the preceding section, service connection for bilateral cataracts was granted in a July 2007 rating decision as a noncompensable disability rated in conjunction with the diabetes mellitus. Initially, the Board notes that the rating schedule for evaluating disabilities of the eyes was revised and amended effective December 10, 2008. See 73 Fed. Reg. 66543-54 (Nov. 10, 2008). The revised criteria apply to all applications for benefits received by VA on or after that date; however, only the old rating criteria may be applied prior to that date. The Veteran's claim for increased rating for diabetes mellitus with bilateral cataract was received in October 2008 and only the old rating criteria are applicable to the instant case. Under the criteria in effect prior to December 10, 2008, preoperative cataracts are rated based on impairment of vision. 38 C.F.R. § 4.84a, Diagnostic Code 6028 (2007). The best distant vision obtainable after best correction by glasses will be the basis of the rating. 38 C.F.R. § 4.75 (2007). Under these criteria, corrected vision of 20/40 or better in both eyes is rated as zero percent disabling. In order to merit the assignment of a compensable rating, corrected vision needs to be at least 20/50 in one eye. 38 C.F.R. § 4.84a The Veteran has not provided any specific argument that he is entitled to a separate, compensable rating for bilateral cataract. The medical evidence in this case indicates that he receives ophthalmological treatment for his cataracts and has undergone several VA examinations to assess the severity of his bilateral cataract. During an April 2009 VA eye examination, the Veteran complained of intermittent, transient blurred vision and that he felt his vision was off. He saw better without glasses and the examiner noted that the eyeglasses were two years old and that it was time for a change in his eyeglass prescription. The examiner also noted that it is normal expected changes. The Veteran also reported that his eyes watered and itched a lot and also felt dry. He was using medication and artificial tears. Physical examination revealed bilateral eye corrected far and near vision of 20/20. Uncorrected right eye far vision was 20/60 and near was 20/100. Uncorrected left eye far vision was 20/50 and near was 20/100. There was no diplopia. The diagnosis was cataracts, right eye greater than left eye, not visually significant yet. The examiner noted that the increase cataracts are a complication of his diabetes, and that the symptom of transient blur or cataracts can be worsened by uncontrolled diabetes. The Veteran underwent a VA eye examination in January 2013. The Veteran denied any current ophthalmologic treatment, but indicated he was previously given a gel for dry eyes. Visual acuity testing revealed right eye uncorrected near vision of 20/25 and far vision of 20/20; corrected near and far vision was 20/20. Left eye uncorrected near vision was 20/40 and far vision of 20/25+2; corrected near and far vision was 20/20. There was no diplopia unless the Veteran stared for a while and can drift to two, but that was infrequent. The diagnoses included cortical cataracts that were not yet symptomatic. The preponderance of the evidence of record is against the assignment of a separate compensable rating for the bilateral cataracts as the Veteran's corrected vision has always been better than 20/40 in either eye. For a higher rating, there needs to at least be 20/50 corrected vision in one eye. 38 C.F.R. § 4.84a. Such has not been shown. Rather, the Veteran was found to have corrected near and far vision of 20/20 in both eyes when examined in April 2009 and January 2013. In sum, the evidence supports the currently assigned noncompensable rating for bilateral cataracts. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Entitlement to a rating in excess of 10 percent for peripheral neuropathy with sural paresthesia and plantar fasciitis of the left and right lower extremities Service connection was originally granted for peripheral neuropathy with sural paresthesia and plantar fasciitis of the left and right lower extremities pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520; each was assigned a 10 percent rating effective July 9, 2001. See May 2002 rating decision. The Veteran filed a claim for an increased rating in October 2008. Diagnostic Code 8520 provides the rating criteria for impairment of the sciatic nerve. Disability ratings of 10 percent, 20 percent and 40 percent are assigned for incomplete paralysis which is mild, moderate or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2016). The words "mild," "moderate," "moderately severe, "and "marked" are not defined in the Rating Schedule or in the regulations during this time period. As such, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The Veteran has not provided any specific argument that he is entitled to ratings in excess of 10 percent for his peripheral neuropathy with sural paresthesia and plantar fasciitis of the left and right lower extremities. The medical evidence in this case consists of several VA examinations that have assessed the severity of his bilateral lower extremity disability. The Veteran underwent a VA peripheral nerve examination in December 2008. He reported he had suffered from flare-ups with resulting pain and weakness. The specific flare-up event was loss of feeling in his legs every day, aggravated by standing up and improved by standing for a while. The frequency was daily; severity was moderate; and duration was a short time, five minutes or less. The Veteran reported being on several medications for treatment without response. He indicated having the following symptoms: tingling of the skin, burning sensation of the skin, and other sensory abnormalities. More specifically, the Veteran reported tingling at times when he wakes up in the morning; that the skin on his legs gets very dry and cracks open; and that the right leg goes numb and locked up when he went to walk. Physical examination revealed left lower extremity motor function neuralgia but no muscle wasting, muscle atrophy, lesion, or loss of fine motor control. The examiner indicated that the major nerve most likely involved was the sciatic nerve. Right lower extremity motor function was normal. The examiner also reported bilateral lower extremity sensory function neuralgia but no muscle wasting, muscle atrophy, lesion, or loss of fine motor control. The examiner indicated that the major nerve most likely involved was the sciatic nerve. The diagnosis was bilateral lower extremity peripheral neuropathy. The Veteran also underwent a VA foot examination in December 2008. He reported that his feet and legs tingled and burned; that at rest, he had pain and stiffness; and that on standing and while walking, he had weakness and stiffness. There was no current treatment and no need for any assistive devices, corrective shoes or shoe inserts. The Veteran reported that he was able to stand and walk more than 30 minutes. Physical examination revealed bilateral foot weakness; abnormal gait, which was described as slow and guarded; and no signs of abnormal weight bearing, skin changes, or vascular changes. There was no flatfoot and weight bearing and non-weight bearing alignment of the Achilles tendon was bilaterally normal. There was no pain on manipulation of the Achilles tendon; no valgus present on either foot; no forefoot or midfoot malalignment on either side; and no hallux valgus. Angulation and dorsiflexion at the first metatarsophalangeal joints was normal on both feet and there was normal active motion bilaterally. Right foot non-weight bearing x-rays showed evidence of arthritis/degenerative changes. Left foot weight bearing and non-weight bearing x-rays showed evidence of arthritis/degenerative changes; pes planus. The diagnoses were peripheral neuropathy of the bilateral foot; left foot pes planus; left foot osteoarthritis; and right foot degenerative osteoarthritis calcaneal spur. The examiner noted that bilateral foot pain was constant and made walking very painful and that the Veteran had limited physical activity due to pain. The Veteran underwent a VA peripheral nerves examination in April 2009. He complained of numbness of both lower extremities since 2008 of a gradual onset with numbness and tingling that is relieved by a change in position or massage. He had no current treatment, paresthesias, dysesthesias or other sensory abnormality; and the condition did not interfere with his usual daily activities. The examiner indicated that the distal sensory nerves of both lower extremities were involved. Physical examination revealed that sensation of both lower extremities was intact to Semmes-Weinstein filament. The examiner specifically indicated that peripheral neuropathy of both lower extremities was not found. The Veteran underwent a VA peripheral nerves conditions DBQ in February 2016, at which time a diagnosis of history of diabetic peripheral neuropathy, bilateral lower extremity, was made. The examiner noted that at the time of diagnosis, there were few to none verifiable, objective physical signs and that the diagnoses of bilateral sciatic peripheral neuropathy with sural nerve anesthesia and plantar fasciitis were apparently based upon subjective report of the Veteran. The Veteran reported symptoms attributable to any peripheral nerve conditions, specifically mild left lower extremity intermittent pain; and mild bilateral lower extremity paresthesias and/or dysesthesias and numbness. He also reported his feet felt very cold at night in bed. Muscle strength testing was normal on bilateral knee extension, ankle plantar flexion and ankle dorsiflexion and there was no muscle atrophy. Reflex examination of the bilateral knee and ankle was normal. Sensory examination for light touch was normal at the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. There were no trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy. Gait was abnormal, but the examiner noted this was due to low back pain, and the Veteran also occasionally used a cane, which was also for low back pain. All the nerves of the lower extremities were reported as normal by the examiner. In the remarks section, the examiner noted there were no objective findings to support a diagnosis of peripheral neuropathy. The examiner noted that the Veteran continued to report sensations of tingling and occasional numbness, left greater than right, but that he denied paresthesias or numbness in the legs. The preponderance of the evidence of record is against the assignment of ratings in excess of 10 percent for the service-connected peripheral neuropathy with sural paresthesia and plantar fasciitis of the left and right lower extremities. The Board acknowledges the subjective complaints reported by the Veteran on VA examination, to include loss of feeling, numbness, tingling, burning sensation, coldness, pain, weakness and stiffness of both lower extremities. The Board also acknowledges that the Veteran reported the severity of his symptoms were moderate during the December 2008 VA peripheral nerves examination. The objective evidence of record, however, does not show that the Veteran's bilateral lower extremity peripheral neuropathy with sural paresthesia and plantar fasciitis is anything more than mild. In this regard, although bilateral lower extremity sensory function neuralgia was noted during the December 2008 VA examination, sensation of both lower extremities was intact to filament testing in April 2009 and sensory examination for light touch was normal in February 2016. Moreover, although motor function neuralgia was reported in the left lower extremity during the December 2008 VA examination, muscle strength and reflex examination was normal in February 2016. The Board acknowledges that the Veteran's gait has been reported as abnormal. The February 2016 VA examiner, however, attributed the change in gait to a low back disability rather than the neurological disability. In sum, the preponderance of the evidence supports the currently assigned 10 percent ratings for peripheral neuropathy with sural paresthesia and plantar fasciitis of the left and right lower extremities. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Entitlement to a compensable rating for right fifth metacarpal fracture Service connection was originally granted for residuals of fracture to the right fifth metacarpal in a July 1981 rating decision, which assigned a noncompensable evaluation . The Veteran filed a claim for an increased rating in October 2008. At this juncture, the Board notes that the November 2009 rating decision denied service connection for right hand arthritis, which the Veteran had claimed in seeking an increase. The Veteran did not appeal that portion of the November 2009 rating decision and that issue is not before the Board for appellate review. The Veteran's right fifth metacarpal fracture is rated by analogy pursuant to Diagnostic Code 5227. Under Diagnostic Code 5227, favorable or unfavorable ankylosis of the ring or little finger is to be rated as noncompensable. 38 C.F.R. § 4.71a. A compensable rating for a finger disability requires amputation, or the functional equivalent thereof. See 38 C.F.R. § 4.71a, Diagnostic Code 5156. With ankylosis, it must also be considered whether an additional evaluation is warranted for resulting limitation of motion of other digits, or for interference with overall function of the hand. See Note following Diagnostic Code 5227. In order for ankylosis to be rated as amputation, the condition must manifest with extremely unfavorable ankylosis. See Note (3)(i) preceding 38 C.F.R. § 4.71a, Diagnostic Code 5216. In other words, in order to be evaluated as amputation, there must be ankylosis of both the metacarpophalangeal and proximal interphalangeal joints with either in extension or full flexion or with rotation or angulation of a bone. Id. Note (3)(ii) explains that if both the metacarpophalangeal and proximal interphalangeal joints of a digit were ankylosed, it should be evaluated as unfavorable ankylosis even if each joint was individually fixed in a favorable position. Note (3)(iii) indicates that if only the metacarpophalangeal or proximal interphalangeal joint were ankylosed, and there was a gap of more than 2 inches (5.1 cm.) between the fingertips and the proximal transverse crease of the palm, with the fingers flexed to the extent possible, the condition should be evaluated as unfavorable ankylosis. In this regard, amputation of the fifth finger warrants a 10 percent rating without metacarpal resection at the proximal interphalangeal joint, or proximal thereto. A 20 percent rating is warranted with full metacarpal resection (more than one-half the bone lost). 38 C.F.R. § 4.71a, Diagnostic Code 5156. The Veteran has not provided any specific argument that he is entitled to a compensable rating for right fifth metacarpal fracture, and the private and VA medical treatment records do not indicate that he has received treatment for this disability. Several VA examinations, however, have been conducted during the pendency of the appeal. The Veteran underwent a VA hand, thumb and fingers examination in April 2009. He reported taking Tylenol as needed and indicated he was right handed. The Veteran complained of aching and stiffness of his right hand with occasional cramping and sharp shooting pain causing him to drop objects. There were no effects on occupational functioning and activities of daily living and no flare-ups of joint disease affecting hand, thumb or fingers. Physical examination revealed no ankylosis. Metacarpophalangeal flexion and proximal interphalangeal joint flexion were both to 30 degrees and the thumb pad faced the finger pads. There was no limitation of motion for any finger. Grip strength was normal and the Veteran was able to touch the fingertips to the transverse crease of the palm. The diagnosis was right hand boxer's fracture. The examiner reported that the Veteran had no arthritis found in the right hand on his x-ray and that review of the chart indicates a diagnosis of arthritis associated with gout and not specifically related to the right hand. Therefore, the claimed arthritis of the right hand secondary to the boxer fracture was not found and was not related to military service. The Veteran underwent a hand and finger conditions DBQ in March 2013. A diagnosis of right metacarpal fracture was noted. He was noted to be right hand dominant. The Veteran reported that flare-ups impacted the function of the hand, specifically noting occasional finger/knuckle pain during cold weather, as in below 40 degrees. Range of motion testing revealed no limitation of motion or evidence of painful motion for any fingers or thumbs. The Veteran was able to perform repetitive-use testing with three repetitions and there was no additional limitation of motion for any fingers post-test. In addition, there was no gap between the thumb pad and the fingers post-test; no gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test; and no limitation of extension for the index finger or long finger post-test. The Veteran did not have any functional loss or functional impairment of any of the fingers or thumbs; and no additional limitation in range of motion of any of the fingers or thumbs following repetitive-use testing. There was no tenderness or pain to palpation for joints or soft tissue of either hand, including thumb and fingers; muscle strength testing was normal; and there was no ankylosis of the thumb and/or fingers. A March 2013 x-ray of the right hand was included, which was normal. The examiner determined that the Veteran's condition did not impact his ability to work. The examiner also noted that when comparing previous x-ray and examination results, there was no degenerative arthritis or decline in function of the right hand. The preponderance of the evidence of record is against the assignment of a compensable rating for the service-connected right fifth metacarpal fracture as there is no evidence of ankylosis of both the metacarpophalangeal and proximal interphalangeal joints of that finger. Rather, the examiners who conducted the April 2009 and March 2013 VA examinations both specifically noted the absence of any ankylosis. In addition, there is no indication that the right fifth metacarpal fracture results in limitation of motion of other digits or interferes with overall function of the right hand. Rather, the April 2009 VA examiner reported that there was no limitation of motion for any finger, that grip strength was normal, and that the Veteran was able to touch the fingertips to the transverse crease of the palm; the March 2013 VA examiner reported that range of motion testing revealed no limitation of motion or evidence of painful motion for any fingers or thumbs and that after repetitive use testing, there was no gap between the thumb pad and the fingers post-test, no gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips, and no limitation of extension for the index finger or long finger. Muscle strength testing was also normal in March 2013. As noted above, once a particular joint is evaluated at the maximum level in terms of limitation of motion, there can be no additional disability due to pain. See Johnston, 10 Vet. App. at 85. Irrespective, the Board notes that the application of DeLuca and 38 C.F.R. §§ 4.40, 4.45, and 4.59 is not warranted in this case as the Veteran was able to perform repetitive-use testing of his right hand digits with three repetitions without any additional limitation of motion for any fingers and the examiner specifically indicated that the Veteran did not have any functional loss or functional impairment of any of the fingers or thumbs. In sum, the preponderance of the evidence supports the currently assigned noncompensable rating for right fifth metacarpal fracture. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Other Considerations The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2016). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). The Board has considered whether the Veteran's disabilities present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2016); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor is whether the disability picture presented in the record is adequately contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111, 118 (2008). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology for his disabilities and provide for additional or more severe symptoms than currently shown by the evidence. The Veteran has not alleged that any of his disabilities result in an exceptional or unusual level of impairment. As his disability picture is contemplated by the rating schedule, the assigned schedular evaluations are, therefore, adequate. Id. at 115. Regardless, the Veteran has not required frequent hospitalization for any of the disabilities on appeal, nor has alleged that there has been marked interference with employment as a result of his disabilities. Accordingly, referral for extraschedular consideration for the disability is not warranted. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. The Court in Yancy v. McDonald, 27 Vet. App. 484, 495 (2016), subsequently held that the Board is required to address whether referral for extraschedular consideration is warranted for a Veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities. Neither scenario applies to the instant case. Finally, the Veteran has not alleged and the evidence does not suggest that he is unemployable as a result of any of his service connected disabilities. Rather, he has reported on several occasions that he retired in 2008 after 33 years of service in the Texas Department of Corrections Juvenile division, and had since periodically worked as a bail bondsman. Accordingly, no action pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009) is warranted. ORDER Service connection for sleep apnea is denied. An initial disability rating in excess of 30 percent for PTSD is denied. A rating in excess of 20 percent for diabetes mellitus is denied. A separate compensable rating for bilateral cataract is denied. A rating in excess of 10 percent for peripheral neuropathy with sural paresthesia and plantar fasciitis of the left lower extremity is denied. A rating in excess of 10 percent for peripheral neuropathy with sural paresthesia and plantar fasciitis of the right lower extremity is denied. A compensable rating for right fifth metacarpal fracture is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs