Citation Nr: 18156984 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 16-50 710 DATE: December 11, 2018 ORDER Service connection for a bilateral hearing loss disability is denied. Service connection for high cholesterol is denied. Service connection for chronic conjunctivitis is denied. A rating of 20 percent, but no greater, for a lumbar spine disability is granted before September 7, 2016; a rating in excess of 10 percent is denied thereafter. A rating of 10 percent, but no greater, for painful limited motion of the right knee is granted before April 19, 2018; a rating in excess of 10 percent is denied thereafter. A rating in excess of 10 percent for instability of the right knee is denied before April 19, 2018; a rating of 10 percent, but no greater, for instability of the right knee is granted thereafter. A rating in excess of 10 percent for plantar fasciitis of the right foot is denied. A rating in excess of 10 percent for plantar fasciitis of the left foot is denied. A rating of 50 percent, but no greater, for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is granted. A compensable rating for allergic rhinitis is denied. REMANDED ISSUES Service connection for obstructive sleep apnea (OSA) is remanded. Service connection for diabetes mellitus, type II (diabetes) is remanded. Service connection for a left shoulder disability is remanded. Service connection for hypertension is remanded. Service connection for glaucoma is remanded. Service connection for fibromyalgia is remanded. A total disability rating on the basis of individual unemployability as the result of service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a bilateral hearing loss disability for VA purposes. 2. High cholesterol is a laboratory finding and not a chronic disability for which benefits may be awarded. 3. The Veteran does not have chronic conjunctivitis. 4. Before September 7, 2016, the Veteran’s lumbar spine disability was manifested by forward flexion functionally limited to not fewer than 30 degrees and not greater than 60 degrees; ankylosis and incapacitating episodes of intervertebral disc disease (IVDS) were not shown. 5. After September 7, 2016, the Veteran’s lumbar spine disability has not been manifested by ankylosis, forward flexion functionally limited to 60 degrees or fewer, a combined range of motion functionally limited to 120 degrees or fewer, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or incapacitating episodes of IVDS. 6. The Veteran’s right knee disability is manifested by a range of motion functionally limited by pain to no fewer than 115 degrees of flexion, full extension, and slight instability; and, a meniscus impairment, ankylosis, impairment of the tibia and fibula, and genu recurvatum were not shown. 7. The Veteran’s bilateral plantar fasciitis does not result in foot symptoms that are moderately severe or worse. 8. The Veteran’s acquired psychiatric disability, to include PTSD, does not result in symptoms of a greater severity than occupational and social impairment with reduced reliability and productivity. 9. The Veteran’s allergic rhinitis does not result in nasal polyps, a complete obstruction on one side, or a greater than 50 percent obstruction on both sides. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 5103, 5107 (2012); 38 C.F.R. §§ 3.159, 3.102, 3.303, 3.304, 3.385 (2018). 2. The criteria for service connection for high cholesterol have not been met. 38 U.S.C. §§ 5103, 5107 (2012); 38 C.F.R. §§ 3.159, 3.102, 3.303, 3.304 (2018). 3. The criteria for service connection for chronic conjunctivitis have not been met. 38 U.S.C. §§ 5103, 5107 (2012); 38 C.F.R. §§ 3.159, 3.102, 3.303, 3.304 (2018). 4. Before September 7, 2016, the criteria for a rating of 20 percent, but no greater, for a lumbar spine disability were met; after September 7, 2016, the criteria for a rating in excess of 10 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code 5242 (2018). 5. Before April 19, 2018, the criteria for a 10 percent rating, but no greater, for painful limited motion of the right knee were met; after April 19, 2018, the criteria for a rating in excess of 10 percent for painful limited motion of the right knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5256, 5260 63 (2018). 6. Before April 19, 2018, the criteria for a rating in excess of 10 percent for instability of the right knee were not met; after April 19, 2018, the criteria for a 10 percent rating, but no greater, for instability of the right knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5257, 5258-59 (2018). 7. The criteria for a rating in excess of 10 percent for plantar fasciitis of the right foot have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5020, 5284 (2018). 8. The criteria for a rating in excess of 10 percent for plantar fasciitis of the left foot have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Codes 5020, 5284 (2018). 9. The criteria for a 50 percent rating, but no greater, for an acquired psychiatric disability, to include PTSD, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.130, Diagnostic Code 9411 (2018). 10. The criteria for a compensable rating for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.97, Diagnostic Code 6522 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1985 to March 1993, from January 2003 to January 2005, and from February 2006 to March 2008. The Appellant has not been provided with an examination addressing his claim for service connection for high cholesterol; indeed, VA does not have a duty to provide an examination in every case. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). VA’s obligation to provide the Appellant with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the claimed disability may be associated with service. See McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). As is discussed in greater detail below, high cholesterol is not a disability for which service connection may be granted, and an examination addressing this condition is unwarranted. There remains no question as to the substantial completeness of the claim. The Board notes that after granting service connection for PTSD, the RO separately developed the Veteran’s claim for service connection for adjustment disorder with depressed mood. Based on the evidence of record, and for convenience and clarity, the Board has consolidated and recharacterized the claim so that it remains as for one psychiatric disorder, including PTSD. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (2009) (because all psychiatric disorders [other than eating disorders] are evaluated under the same criteria, it is appropriate to assign a single evaluation encompassing all service-connected psychiatric symptoms, regardless of how they are diagnosed). Service Connection In general, service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a nexus between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement for service connection that a current disability be present is, however, satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007) (a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Service Connection for a Bilateral Hearing Loss Disability Impaired hearing is a disability when: (a) the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or (b) the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000 or 4000 Hertz are 26 decibels or greater, or (c) speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran filed his claim for service connection for a bilateral hearing loss disability in March 2011. The Veteran underwent VA audiological examinations in May 2011 and September 2016. In neither examination did the Veteran’s auditory thresholds or his speech recognition scores meet the definition of a bilateral hearing loss disability as set forth above. Furthermore, the Veteran’s available treatment records do not show treatment for a bilateral hearing loss disability. To the contrary, clinicians, for example in April 2011, April 2012, and July 2016 have noted no hearing problems in the Veteran. To the extent that the Veteran indeed believes that he experiences symptoms of impaired hearing, the Veteran is competent to testify as to readily observable symptoms such as diminished hearing and ringing in his ears. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran is not, however, competent to opine as to whether his impaired hearing constitutes a disability, which requires a degree of loss consistent with the criteria set forth above. Furthermore, the Veteran has often denied experiencing changes in hearing to clinicians. The Board, therefore, finds that the weight of the evidence does not establish the presence of a bilateral hearing loss disability. Accordingly, the Board concludes that the criteria for service connection for a bilateral hearing loss disability have not been met, and the claim is denied. Service Connection for High Cholesterol High cholesterol, also known as hyperlipidemia, is an “excess of cholesterol in the blood.” Dorland’s Illustrated Medical Dictionary 792 (28th ed. 1994). Hyperlipidemia is “a general term for elevated concentration of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc.” Id. at 795. Hyperlipidemia and elevated cholesterol are laboratory findings and are not themselves disabilities for VA purposes. 61 Fed. Reg. 20,440, 20,445 (May 7, 1996). The term “disability,” as used for VA purposes, refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). There is no evidence of record suggesting that the Veteran’s elevated cholesterol causes any impairment of earning capacity. As discussed in Brammer, service connection can only be granted for a disability resulting from disease or injury. High cholesterol is a laboratory finding that manifests itself only in laboratory test results and is not a disability for which service connection can be granted. Service connection for high cholesterol is therefore unwarranted. Service Connection for Chronic Conjunctivitis The Veteran filed his claim for service connection for chronic conjunctivitis in March 2011. The Veteran underwent a VA examination in September 2012, at which time the examiner found that the Veteran did not suffer from chronic conjunctivitis. VA treatment records are also negative for any current complaints or treatment for chronic conjunctivitis. Instead, the Veteran’s treatment records indicate only that the Veteran reported a remote history of conjunctivitis. To the extent that the Veteran indeed believes that he experiences symptoms of conjunctivitis, the Veteran is competent to testify as to readily observable symptoms such as eye pain. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran is not, however, competent to opine as to whether his symptoms constitute a disability, and no clinicians have found that the Veteran currently suffers from chronic conjunctivitis. The Board, therefore, finds that the weight of the evidence does not establish the presence of chronic conjunctivitis. Accordingly, the Board concludes that the criteria for service connection have not been met, and the claim is denied. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, staged ratings have been assigned, and as discussed below, the evidence does not support the assignment of any additional staged rating periods other than those discussed herein. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding—the evaluation of the same manifestation of a disability under different diagnostic codes—is to be avoided when rating a veteran’s service connected disabilities. 38 C.F.R. § 4.14. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon tie up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are related considerations. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Increased Rating for a Lumbar Spine Disability The Veteran’s lumbar spine disability is rated 10 percent disabling under Diagnostic Code 5242, applicable to degenerative arthritis of the spine. Spine disabilities are evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R § 4.71a, Diagnostic Code 5242. The General Rating Formula for Diseases and Injuries of the Spine rates back disabilities as follows, in pertinent part: 20 percent: Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 40 percent: Forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. 50 percent: Unfavorable ankylosis of the entire thoracolumbar spine. 100 percent: Unfavorable ankylosis of the entire spine. 38 C.F.R § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. “Ankylosis” is immobility and consolidation of a joint due to a disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Formula for Rating IVDS Based on Incapacitating Episodes rates lumbar spine disabilities as follows, in pertinent part: 20 percent: Incapacitating episodes having a total duration of at least two weeks but fewer than four weeks during the past 12 months. 40 percent: Incapacitating episodes having a total duration of at least four weeks but fewer than six weeks during the past 12 months. 60 percent: Incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R § 4.71a, Diagnostic Code 5243 (2017). An “incapacitating episode” is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. 38 C.F.R § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Turning to the facts in this case, the Veteran filed his underlying claim for service connection for a lumbar spine disability in December 2009. In March 2010, a clinician noted that the Veteran’s thoracic movement was normal in all planes without pain. The Veteran’s lumbar flexion was limited as the result of hamstring tightness, and his extension was normal. The Veteran underwent a VA examination in April 2010, at which time the Veteran complained of pain and stiffness across his lower back. The Veteran experienced severe flare-ups approximately three times a week, with each flare-up lasting several hours. Flare-ups were precipitated by strenuous activity and were alleviated with rest and medication. Prolonged walking and standing aggravated the Veteran’s back pain, but he was able to work through it. The Veteran denied having any incapacitating episodes in the preceding 12 months. The examiner observed that the Veteran had flattening of the lumbar spine and tenderness of the spine. The Veteran had forward flexion to 65 degrees with pain at 40 degrees, extension to 25 degrees with pain at 20 degrees, bilateral lateral flexion to 25 degrees with pain at 20 degrees, and bilateral lateral rotation to 25 degrees with pain at 20 degrees. Repetitive testing did not result in additional limitation of motion or functional impairment. The examiner diagnosed the Veteran with degenerative disc disease of the lumbar spine. The Veteran underwent an additional VA examination in April 2012, at which time the Veteran complained of muscle spasms and nearly-constant low back pain that worsened with bending, lifting, and prolonged sitting. The Veteran experienced severe flare-ups approximately twice a week, with each flare-up lasting three to four days. The Veteran had forward flexion to 90 degrees with pain at 60 degrees, extension to 30 degrees with pain at 25 degrees, bilateral lateral flexion to 30 degrees with pain at 25 degrees, and bilateral lateral rotation to 25 degrees with pain at 20 degrees. Repetitive testing did not result in additional limitation of motion or functional impairment. The Veteran had tenderness and pain to palpation of the back, but no guarding or muscle spasm. The examiner noted that the Veteran had IVDS, but he had not experienced any incapacitating episodes over the preceding 12 months. The Veteran underwent an additional VA examination in September 2016, at which time the Veteran complained of persistent back pain. The Veteran denied experiencing flare-ups of his symptoms, and the Veteran denied experiencing functional loss. The Veteran had forward flexion to 75 degrees, extension to 30 degrees, bilateral lateral flexion to 30 degrees, and bilateral lateral rotation to 30 degrees. The examiner noted that the Veteran showed pain with all ranges of motion, but such pain did not result in a functional loss. Repetitive testing did not result in additional limitation of motion or functional impairment. There was no tenderness, pain on palpation, guarding, or muscle spasm. The examiner found that the Veteran did not have IVDS. Turning to an analysis of these facts, the Veteran’s lumbar spine disability has been rated 10 percent disabling throughout his appeal. With regard to a rating in excess of 10 percent, the Veteran’s lumbar spine has not been ankylosed, or immobile, at any time. Furthermore, the Veteran’s lumbar spine has not shown forward flexion limited to 30 degrees or fewer at any time, even when taking pain into consideration. Without ankylosis or such a limitation of motion, a rating of 40 percent or greater for the Veteran’s back disability is unwarranted at any time. With regard to a 20 percent rating, the Veteran showed forward flexion limited to 40 degrees by pain in April 2010, and forward flexion limited to 60 degrees by pain in April 2012. Such a limitation of forward flexion is consistent with a 20 percent rating, which provides that forward flexion between 30 degrees and 60 degrees warrants a 20 percent rating. As of the Veteran’s September 2016 examination, however, he showed forward flexion to 75 degrees, and his pain did not result in additional functional impairment. Furthermore, in September 2016, the combined range of motion of the thoracolumbar spine was not limited to 120 degrees or fewer, even when taking pain into consideration. The Veteran has not shown muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Thus, the Board finds that a 20 percent rating for the Veteran’s lumbar spine disability is warranted before his September 7, 2016, examination, and a rating in excess of 10 percent is unwarranted thereafter. In reaching this conclusion, the Board considered functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board has considered the effects of weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45. Although the Board accepts the Veteran’s assertions that his back disability causes him to experience pain, the Board has taken this into account in its above discussion of range of motion. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36 38 (2011). Furthermore, even when the Veteran’s complaints of pain are considered, the Board concludes that the overall manifestations of his spine disability generally do not demonstrate a degree of functional loss so as to warrant higher ratings for the period on appeal. Ratings in excess of those currently assigned are unavailable under the formula for rating IVDS. Greater ratings based on IVDS would require incapacitating episodes with a total duration of at least two weeks during a 12 month period. In this case, to the extent that the Veteran indeed has IVDS, bed rest has not been prescribed at any time during the course of the appeal. In sum, the criteria for a rating in excess of 10 percent based on IVDS have not been met. Turning now to an evaluation of the neurological manifestations of the Veteran’s back disability, a compensable evaluation of the Veteran’s neurological symptoms would require a finding that such symptoms approximate at least mild incomplete paralysis. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. In April 2010, the Veteran denied any radiation of pain to his lower extremities, but he indicated that he had numbness and weakness in the thighs. The Veteran had full strength in the lower extremities, and sensation was intact to light touch. Reflex testing was normal. In April 2012, muscle strength, reflex, and sensory testing were normal. The Veteran denied experiencing any signs or symptoms of radiculopathy. The Veteran reported that he constantly wore a back brace. In September 2016, muscle strength, reflex, and sensory testing were normal. The Veteran denied experiencing any signs or symptoms of radiculopathy. Upon review of these facts, the Board finds that to the extent the Veteran suffers from neurological symptoms, such symptoms are no more than slight. The Veteran himself has not alleged that he experiences significant neurological symptoms as a result of his back disability. Clinicians have not indicated that the Veteran experiences neurological manifestations of a back disability. Accordingly, the Board finds that the Veteran’s neurological symptoms do not rise to the level of mild incomplete paralysis, and a compensable rating addressing neurological manifestations of the Veteran’s back disability is unwarranted. Increased Rating for a Right Knee Disability The Veteran’s right knee disability has been rated 10 percent disabling throughout the period on appeal, but the diagnostic code used to evaluate the disability has changed. Before April 19, 2018, the right knee disability was evaluated under Diagnostic Code 5257, applicable to recurrent subluxation or lateral instability; since April 19, 2018, the right knee disability has been evaluated under Diagnostic Code 5260, applicable to limitation of flexion. The Board will first address the issue of entitlement to a greater rating based on limitation of motion of the right knee. Separate evaluations may be assigned for limitation of flexion and extension of the same knee joint. Specifically, when a veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. In pertinent part, limitation of flexion to 45 degrees warrants a 10 percent rating; to 30 degrees warrants a 20 percent rating, and; to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. In pertinent part, limitation of extension to 10 degrees warrants a 10 percent rating; to 15 degrees warrants a 20 percent rating; to 20 degrees warrants a 30 percent rating; to 30 degrees warrants a 40 percent rating, and; to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Turning to the facts in this case, the Veteran filed his claim of entitlement to an increased rating for a right knee disability in April 2011. The Veteran underwent a VA examination in December 2012, at which time the Veteran complained of chronic, worsening pain. The Veteran denied experiencing flare-ups of symptoms relating to his right knee. The Veteran had right knee flexion to 120 degrees with pain at 115 degrees, and right knee extension to 0 degrees without pain. Repetitive use testing did not result in additional limitation of motion or other functional loss. The examiner noted that the Veteran had functional loss in the form of less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The Veteran did not have tenderness or pain to palpation of the right knee. The Veteran underwent an additional VA examination in September 2016, at which time he reported experiencing right knee pain with weight-bearing. The Veteran denied experiencing flare-ups of symptoms relating to his right knee. The Veteran had right knee flexion to 140 degrees with pain and extension to 0 degrees. The examiner noted that the Veteran’s pain did not result in a functional loss, and the Veteran did not show pain with weight-bearing. Repetitive use testing did not result in additional limitation of motion or other functional loss. The Veteran had tenderness or pain to palpation of the anterior aspect of the right knee. The Veteran underwent a VA contract examination in April 2018, at which time he complained of flare-ups of symptomatology of the right knee. During these flare-ups, the right knee felt hot and throbbing. He complained of continuous pain when standing. The Veteran had right knee flexion to 120 degrees and extension to 0 degrees. While the Veteran complained of pain, the examiner noted the Veteran’s pain did not result in a functional loss, and the Veteran did not show pain with weight-bearing. Repetitive use testing resulted in right knee flexion to 115 degrees and extension to 0 degrees, with additional functional loss in the form of pain and fatigue. The examiner found that pain, weakness, fatigability, or incoordination significantly limited the functional ability of the right knee with repeated use over time, limiting flexion to 115 degrees. The Veteran did not have tenderness or pain to palpation of the right knee. The Veteran had weakened movement, instability of station, disturbance of locomotion, and interference with standing. Turning to an analysis of this evidence, the Veteran’s right knee disability was not rated on the basis of limitation of motion before April 19, 2018, and it has been rated 10 percent disabling on the basis of a limitation of flexion since that date. Before April 19, 2018, the evidence does not show flexion of the right knee limited to 45 degrees or fewer, even when taking pain into consideration. Since that date, the evidence does not show flexion of the right knee limited to 30 degrees or fewer, even when taking pain into consideration. The Board thus finds that a compensable rating based on a limitation of flexion is unavailable before April 19, 2018, and a rating in excess of 10 percent based on a limitation of flexion is unavailable thereafter. 38 C.F.R. § 4.71a, Diagnostic Code 5260. With respect to an increased rating based on limitation of extension, the evidence does not demonstrate a limitation of right knee extension at any time, even when taking pain into consideration. A separate rating based on a limitation of extension, which would require extension limited to 10 degrees or greater, is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board must additionally consider functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. VA examiners have noted the Veteran’s complaints such as pain, and the Board has taken those complaints into consideration in its above discussion. The Board finds that the evidence does not support a finding that the Veteran’s functional loss causes disability beyond the above discussed range of motion testing. While the Board accepts the credible contentions of the Veteran that his right knee disability causes him to experience pain, the Board has taken that into account in its consideration of the range of motion of the Veteran’s right knee. To the extent, however, that the schedular criteria indicate that painful motion is entitled to at least the minimum compensable rating for the joint, a minimum 10 percent rating applies to the Veteran’s right knee disability before April 19, 2018, and a 10 percent rating is granted on the basis of painful motion before April 19, 2018. 38 C.F.R. § 4.59. Having determined that the Veteran’s right knee disability is entitled to single 10 percent rating based on painful limitation of motion throughout the period on appeal, the Board next turns to the possibility of greater ratings based on instability. Limitation of motion and instability of the knee may be rated separately, provided that any separate rating must be based upon additional disability. Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). The Veteran’s right knee disability was rated 10 percent on the basis of instability before April 19, 2018, and it has not been on the basis of instability since that date. When the semilunar cartilage (that is, the meniscus) is dislocated with frequent episodes of locking, pain and effusion into the joint, a 20 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5258. When semilunar cartilage has been removed, but remains symptomatic, a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5259. The Board acknowledges that certain clinicians, for example the April 2018 examiner, have stated that the Veteran experienced a meniscal tear of the right knee. With that said, the evidence does not, in fact, show that the Veteran has ever suffered from an impairment of the meniscus of the right knee. The evidence instead shows that the Veteran has experienced a tear of the left meniscus with subsequent arthroscopic knee surgery. Clinical statements suggesting that the Veteran has a right meniscus condition appear to be based solely on the Veteran’s reported history, rather than on medical evidence such as imaging studies, physical examination. Compensable ratings under Diagnostic Codes 5258 and 5259 are thus unavailable. Under Diagnostic Code 5257, recurrent subluxation or lateral instability is rated at 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a. Lay evidence as to lateral instability should be weighed on a case-by-case basis. English v. Wilkie, No. 17-2083, U.S. Vet. App. (Nov. 1, 2018). The terms slight, moderate, and severe are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just as contemplated by the requirements of the law. 38 C.F.R. § 4.6. In December 2012, the Veteran wore a brace and used a cane with excessive walking. Joint stability testing was normal, and the examiner noted no history of recurrent patellar subluxation or dislocation. The examiner noted that the Veteran had not experienced any meniscal conditions or surgical procedures for a meniscal condition. In March 2014, a clinician noted that the Veteran had mild crepitus of the right knee. In September 2016, the Veteran reported that he occasionally wore a right knee brace for support. The right knee showed no objective evidence of crepitus. Joint stability testing was normal, and the examiner noted no history of recurrent effusion, patellar subluxation, or patellar dislocation. In April 2018, the Veteran indicated that his right knee locked up sometimes. The right knee showed no objective evidence of crepitus. Joint stability testing was normal, and the examiner noted no history of recurrent effusion, patellar subluxation, or patellar dislocation. The examiner noted that the Veteran had experienced a meniscal tear of the right knee with frequent episodes of joint pain. Turning to an analysis of these facts, the Board first finds that the symptom picture associated with the Veteran’s right knee instability has remained relatively constant throughout the period on appeal. Thus, to the extent the Veteran was awarded a 10 percent rating on the basis of instability before April 19, 2018, the Board finds that such a rating should continue after that date, because the Veteran’s complaints of instability remained unchanged. With that said, the Board finds that the symptoms of right knee disability have never approximated the “moderate” severity that would be required for a greater 20 percent rating before April 19, 2018. Joint stability testing was consistently normal, and clinicians found that the Veteran had no history of patellar subluxation or dislocation. Thus, the Board finds that a 10 percent rating on the basis of instability is warranted as of April 19, 2018, but a rating in excess of 10 percent of the basis of right knee instability is unavailable at any time. Increased Ratings for Bilateral Plantar Fasciitis The plantar fasciitis affecting both of the Veteran’s feet is rated 10 percent rating for each foot under Diagnostic Code 5020, applicable to synovitis of the feet. Synovitis is rated on the basis of limitation of motion of the affected part of the body, as degenerative arthritis. 38 C.F.R. § 4.71a. Disabilities of the feet are otherwise generally evaluated under Diagnostic Codes 5276 5284. 38 C.F.R. § 4.71a. With that said, Diagnostic Codes 5276 (flatfoot), 5277 (weak foot), 5278 (claw foot), 5279 (metatarsalgia), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), and 5283 (tarsal or metatarsal bones, malunion of, or nonunion of) do not apply because the Veteran has not been service-connected for such disabilities; instead, Veteran is service connected for plantar fasciitis of the bilateral feet. Under Diagnostic Code 5284, applicable to “other” foot injuries, a 10 percent evaluation applies to moderate foot injuries, a 20 percent evaluation applies to moderately severe foot injuries, and a 30 percent evaluation applies to severe foot injuries. Diagnostic Code 5284 refers to “other” foot injuries and applies to foot disabilities for which there is not already a specific diagnostic code. The Court has held that when a when a condition is specifically listed in the Rating Schedule, it may not be rated by analogy under Diagnostic Code 5284. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). Words such as “moderate” and “severe” are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Board observes in passing that “moderate” is defined as “of average or medium quality, amount, scope, range, etc.” Webster’s New World Dictionary, Third College Edition (1988) 871. Turning to the facts in this case, the Veteran filed his underlying claim for service connection for a bilateral foot disability in December 2009. The Veteran underwent a VA examination in April 2010, at which time he complained of experiencing bilateral heel pain about once a week. The Veteran complained of fatigability, but he denied experiencing weakness. Upon physical examination, the examiner diagnosed the Veteran with bilateral plantar fasciitis. The Veteran underwent an additional VA examination in April 2012, at which time examiner diagnosed the Veteran with plantar fasciitis. The Veteran complained of nearly-constant aching and some tingling of the bilateral feet. The Veteran underwent an additional VA examination in September 2016, at which time the examiner diagnosed the Veteran with asymptomatic plantar fasciitis. The Veteran indicated that his pain was improved with orthopedic shoes and inserts, and he stated that his bilateral plantar foot pain occurred only after prolonged walking and standing. The Veteran reported standing for 6 hours out of his 8 working hours. The Veteran denied experiencing flare-ups of his symptoms, and he denied experiencing a functional loss or impairment of the feet. There was no pain upon physical examination of the feet. The examiner found that the Veteran experienced no functional loss attributable to his plantar fasciitis. Turning to an analysis of these facts, the Board finds that the Veteran is not entitled to ratings in excess of 10 percent under the Diagnostic Code applicable to synovitis. Synovitis, which is to be rated as degenerative arthritis on the basis of limited motion, does not provide for a greater rating both because the Veteran’s plantar fasciitis is already rated 10 percent disabling for both feet, and because the Veteran’s plantar fasciitis has not resulted in an impairment of motion of the feet. The Board otherwise finds that ratings in excess of 10 percent are unavailable under the Diagnostic Code applicable to “other” foot injuries. Greater ratings would require symptoms that are “moderately severe” or worse in nature. The Veteran does not show such symptoms. No clinician has characterized the Veteran’s bilateral plantar fasciitis as moderately severe, and the Board finds that the Veteran’s symptoms are not moderately severe or worse. The Veteran’s plantar fasciitis has resulted, at worst, in symptoms of aching and tingling with prolonged standing. The September 2016 examiner found the Veteran’s plantar fasciitis to be essentially asymptomatic. These symptoms are not moderately severe or worse, and ratings in excess of 10 percent are unavailable for the Veteran’s bilateral plantar fasciitis. Increased Rating for PTSD The Veteran is in receipt of a 10 percent rating for PTSD before January 4, 2016, and a 30 percent rating thereafter. Under the General Rating Formula for Mental Disorders, in pertinent part, a 30 percent rating applies to 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, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating applies to 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 compete 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 rating applies to 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); an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when a psychiatric disorder causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. Id. When rating a mental disorder, VA must consider the frequency, severity, and duration of the Veteran’s psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency must assign a rating 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. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. Furthermore, the specified factors for each incremental rating are examples, rather than requirements, for a particular rating. The Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating criteria. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Indeed, the symptoms listed under § 4.130 are not intended to serve as an exhaustive list of the symptoms that VA may consider but as examples of the type of degree of symptoms, or the effects, that would warrant a particular rating. Mauerhan, 16 Vet. App. at 442 (2002). The Veteran’s actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez Claudio v. Shinseki, 713 F.3d 112, 116 17 (Fed. Cir. 2013). Also relevant to the Board’s analysis is the Global Assessment of Functioning (GAF) score assigned to the Veteran, which is a scale that indicates the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM IV); 38 C.F.R. § 4.130 (2017). While a GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when assigning a disability rating. VAOPGCPREC 10 95. The Veteran filed his underlying claim of entitlement to service connection for PTSD in December 2009. The Veteran underwent a VA examination in April 2010, at which time the Veteran reported having good relationships with his mother, sister, and two adult children. The Veteran had been married to his current spouse for 22 years, and he described his relationship as “good and bad”. The Veteran described having good friends. The examiner found that the Veteran’s psychiatric symptoms resulted in deficiencies in his family relations, with the Veteran’s stress and mood affecting his relationship with his spouse. The Veteran was studying for a degree in information technology, and he indicated that he did not have time to engage in many leisure pursuits because he worked two full-time jobs as a nursing assistant and sorter at a distribution center. The Veteran reported that he had lost 16 weeks of work during the preceding 12-month period as a result of stress and depression. The examiner found the Veteran to be competent to manage his financial affairs. The examiner found that the Veteran had reduced reliability and productivity due to PTSD symptoms, noting that the Veteran reported that he had to take four months off of both of his jobs as a result of significant depression. The Veteran underwent an additional psychiatric examination in May 2011, at which time the examiner noted that the Veteran had been married for 24 years and had two adult children. The Veteran reported not having any friends, and he watched television as a leisure activity. The examiner found that the Veteran had mild to moderate social inhibition as a result of his anxiety symptoms. The Veteran had completed an associates degree in general studies in 2010. The Veteran reported that he had been on sick leave from work since January 2011. The Veteran reported sleeping 4 to 5 hours nightly, with his sleep interrupted by nightmares. The Veteran complained of chronic, daily depression, with crying spells at least twice weekly. The Veteran experienced frequent, chronic, moderate-to-severe intrusive and distressing memories. The Veteran avoided thinking and talking about his trauma. The examiner found that the Veteran had “moderate” symptoms of PTSD, and had symptoms that were transient or mild and decreased work efficiency and his ability to perform occupational tasks only during periods of significant stress. The examiner assigned the Veteran a GAF score of 55. The Veteran underwent an additional VA examination in September 2012, at which time the Veteran reported that he was married and had two adult children. The Veteran indicated that he had lost both of his jobs during the preceding year, and he was working a job in security at the time of the examination. The Veteran was additionally taking college classes online. The examiner found the Veteran to be capable of managing his financial affairs. The Veteran reported having mood swings, experiencing a lack of pleasure in activities, and a decline in sexual activity. The Veteran reported experiencing forgetfulness and always felt tired. The examiner noted that the Veteran suffered from depressed mood, anxiety, and chronic sleep impairment. The examiner found that the Veteran’s symptoms resulted in an occupational or social impairment due to mild or transient symptoms that decreased work efficiency and his ability to perform occupational tasks only during periods of significant stress, or his symptoms were controlled by medication. The Veteran underwent an additional VA examination in September 2016, at which time the examiner noted that the Veteran was married, and he lived with his spouse, his daughter, and his granddaughter. The Veteran reported having a couple of friends, but “they [were] all busy”. The Veteran reported having a loss of interest in activities that once interested him, such as going to sporting events. The Veteran was employed in the security field. The Veteran reported liking his job but having disagreements with his management. The Veteran reported that he “failed out” of an attempt to obtain a degree in information technology. The examiner found the Veteran to be capable of managing his financial affairs. The examiner found that the Veteran suffered from a depressed mood, anxiety, and chronic sleep impairment. The examiner found that the Veteran suffered from occupational and social impairment due to mild or transient symptoms that decreased work efficiency and his ability to perform occupational tasks only during periods of significant stress, or his symptoms were controlled by medication. In a September 2016 neuropsychiatric examination, the Veteran reported that he was working full-time in the security field. The Veteran complained of difficulties with attention and concentration, and he indicated that he had recently failed two online classes. The Veteran reported having a very poor mood, but he felt that his ability to seek treatment was limited as a result of his work schedule. The Veteran stated that he had a “good support system”, but he could not identify anyone whom he could confide in. The Veteran felt supported by his spouse, but he did not wish “to burden her with his issues”. The Veteran felt that his mood was worsening, and he noted the fluctuation between his mood and cognitive symptoms. Testing revealed no evidence of neuropsychological dysfunction, but the Veteran showed severe symptoms of depression. In September 2016, a private clinician opined that the Veteran’s PTSD had caused impairment of his occupational and social functioning with deficiencies in most areas such as work, family relations, judgment, thinking, and mood since at least December 2009. The clinician noted that the Veteran had been unable to complete sufficient technical or vocational training or obtain a college degree that would allow him to pursue a career or steady occupation over time. The clinician noted that the Veteran had held a variety of short or longer-term jobs, the clinician found that the Veteran’s PTSD played a significant role in his inability to pursue a career, or a single, steady occupation with opportunities for advancement over time. The clinician noted that the Veteran’s PTSD symptoms strained his family relationships. The clinician indicated that the Veteran lived with his spouse and daughter, who were sources of stress and irritation to the Veteran. The Veteran’s spouse and daughter did not “adhere to his compulsive standards of cleanup and maintenance around the home”. The Board has additionally reviewed the Veteran’s psychiatric treatment records, which show a symptom picture that is consistent with the above examination reports. The Veteran’s psychiatric records, for example from June 2016, indicate that the Veteran complained of withdrawal, isolation, a lack of motivation, anxiety, intrusive memories, and sleep problems. Turning to an analysis of these facts, the Board first finds that the symptomatology associated with the Veteran’s PTSD has remained relatively constant since the Veteran filed his underlying claim of entitlement to service connection. The Veteran’s currently staged rating of 10 percent before January 4, 2016, and 30 percent thereafter, is not justified by the evidence that shows a steady psychiatric symptomatology. It is not apparent from the evidence that the Veteran’s symptomatology underwent a worsening as of the Veteran’s date of treatment on January 4, 2016. In that context, the Board will next determine the appropriate rating for the Veteran’s psychiatric symptoms throughout the period on appeal. The Board concludes that while the weight of the evidence indeed shows that the Veteran has experienced a degree of occupational or social impairment consistent with a 50 percent rating. A 50 percent rating is warranted for the entire appeal period. However, the Veteran has not experienced a degree of impairment consistent with a rating greater than 50 percent at any time. With regard to the Veteran’s occupational impairment, the Veteran has not at any time shown the total occupational impairment that is associated with a 100 percent disability rating or the occupational impairment with deficiencies in most areas that is associated with a 70 percent disability rating. The Veteran has been employed in the fields of nursing, sorting, and security since filing his underlying claim of entitlement for service connection. The Veteran has, at times, worked two full-time jobs while pursuing an online degree. Clinicians have consistently found the Veteran to be able to handle money, pay bills, and manage his own financial affairs. No examiner has found the Veteran to suffer from a degree of occupational impairment associated with a 70 percent rating or greater. The Board acknowledges that the September 2016 private clinician opined that the Veteran’s occupational impairment met the criteria associated with a 70 percent rating. The Board disagrees. The clinician essentially opined that the Veteran’s inability to pursue a “better positioned” “career or steady occupation” as a result of his symptoms supported a 70 percent rating. While this may be so, a 70 percent rating contemplates occupational impairment with deficiencies in most areas. The Veteran’s ability to independently manage his financial affairs, in addition to his consistently maintaining employment, albeit not at his preferred level of responsibility, is inconsistent with a finding that the Veteran suffered from occupational impairment with deficiencies in most areas. Instead, at worst, examiners have noted that the Veteran has “moderate” degree of impairment as a result of his PTSD symptoms. The Veteran has moved from one position to another, experienced frustration with management, and experienced difficulty in successfully completing online courses in furtherance of his career. Such reflects symptoms most consistent with a 50 percent disability rating, which contemplates occupational impairment with reduced reliability and productivity. Similarly, with regard to the Veteran’s social impairment, the Veteran has not at any time shown the total social impairment that is associated with a 100 percent disability rating, or the social impairment with deficiencies in most areas that is associated with a 70 percent disability rating. In support of this finding, the Board notes that the Veteran has maintained a decades long marriage with his spouse throughout the course of the appeal, and the Veteran lived with his spouse, his adult daughter, and his granddaughter. At times, for example in April 2010 and September 2016, the Veteran described having friends; at other times, for example in May 2011, the Veteran described not having friends. While the Board acknowledges the Veteran’s descriptions of withdrawing from others and experiencing depression, anxiety, and anger, the Veteran’s self reported satisfaction with his familial relationships is not consistent with the inability to establish and maintain effective relationships that is associated with a rating of 70 percent or greater. No examiner has found the Veteran to be socially impaired to the degree contemplated by a 70 percent disability rating or greater. The Board acknowledges that the September 2016 private clinician opined that the Veteran’s social impairment met the criteria associated with a 70 percent rating. The Board disagrees. While the clinician described the effect of symptoms such as depression, anxiety, and compulsive behavior on his familial relationships, a 70 percent rating contemplates an inability to maintain effective relationships. The evidence shows that the Veteran’s symptoms have indeed affected his personal relationships, for example, causing the Veteran to have difficulty confiding in his spouse. The Veteran has nonetheless maintained relationships with his family throughout the appeal, and the Board thus finds that a rating of 70 percent or greater is unwarranted on the basis of the Veteran’s social impairment. Instead, at worst, examiners have noted that the Veteran has “moderate” degree of impairment as a result of his PTSD symptoms. The Veteran has complained of feelings of social isolation and difficulty connecting with others. The evidence shows difficulty in establishing and maintaining his social relationships. The Board notes that the Veteran’s symptoms are most consistent with a 50 percent disability rating, which contemplates social impairment with reduced reliability and productivity. To the extent the Veteran has shown certain symptoms associated with ratings greater than 50 percent, the Board, upon review of the Veteran’s entire symptom picture, cannot find that such symptoms have at any time resulted in functional impairment sufficient to justify a rating in excess of 50 percent. For example, the Board notes that the obsessional rituals that the September 2016 clinician described are associated with a 70 percent rating for PTSD. Upon review of the totality of the evidence, however, while the record arguably shows the presence of certain symptoms that are associated with greater ratings, these symptoms have not contributed to a degree of occupational and social impairment consistent with a rating greater than 50 percent. In making this determination, the Veteran’s GAF scores have been considered. The Board finds that these scores, which are reflective of mild to moderate symptoms, and particularly when considered along with the symptoms contained in the associated clinical reports, are consistent with a 50 percent rating for PTSD. Accordingly, the Board finds that a 50 percent rating, but no greater, for PTSD is warranted. Increased Rating for Allergic Rhinitis The Veteran is in receipt of a noncompensable rating for allergic rhinitis under Diagnostic Code 6522, applicable to allergic or vasomotor rhinitis. Under this Diagnostic Code, a 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps but with either greater than 50 percent obstruction of nasal passage on both sides or complete obstruction of one side. A 30 percent rating is warranted for allergic or vasomotor rhinitis with polyps. 38 C.F.R. § 4.97. Turning to the facts in this case, the Veteran filed his underlying claim for service connection for allergic rhinitis in March 2011. The Veteran underwent a VA examination in September 2012, at which time the Veteran complained of year-round congestion. The Veteran reported using flunisolide nasal spray multiple times a day. The Veteran’s rhinitis did not result in a greater than 50 percent obstruction of the nasal passage on both sides, complete obstruction on one side, permanent hypertrophy of the nasal turbinates, or nasal polyps. The Veteran underwent an additional VA examination in September 2016, at which time the Veteran indicated that he had difficulty breathing as a result of nasal congestion. The Veteran’s rhinitis did not result in a greater than 50 percent obstruction of the nasal passage on both sides, complete obstruction on one side, permanent hypertrophy of the nasal turbinates, or nasal polyps. Turning to an analysis of this evidence, the Board acknowledges that the Veteran has complained of nasal congestion. With that said, a compensable rating under the criteria applicable to allergic rhinitis require symptoms beyond nasal congestion. The Veteran does not have a total obstruction of either side, a greater than 50 percent obstruction on both sides, or polyps. The criteria for a compensable rating for the Veteran’s rhinitis have therefore not been met. The Board has also considered the other rating criteria for diseases of the nose. However, there is no evidence that the Veteran has had a deviated nasal septum, loss of part of or scars of the nose, or bacterial or granulomatous rhinitis at any time during the appeal period. A compensable rating is unavailable under the rating criteria applicable to any diseases of the nose. REASONS FOR REMAND The Veteran has claimed that his OSA is related to his military service. The Veteran reported experiencing in-service symptoms such as insomnia (January 2007), which the Veteran attributes to OSA. Following service, the Veteran was formally diagnosed with OSA in January 2010, and he has received treatment for OSA since that time. With a current diagnosis of OSA and the suggestion of an in-service event (insomnia), the Veteran should be provided a VA examination. The Veteran has claimed that his diabetes is related to his military service. A September 2007 laboratory report showed that the Veteran had elevated glucose, measuring 165 mg/dl, with a reference range of 70mg/dl to 110 mg/dl. Following service, the Veteran was noted to have impaired fasting glucose in September 2008, he was diagnosed with diabetes in 2010, and he has received treatment for diabetes since that time. With a currently diagnosis of diabetes and the suggestion of an in-service event, the Veteran should be provided a VA examination. The Veteran has claimed that his left shoulder disability is related to his military service. The Board notes that the Veteran complained of left shoulder pain in-service, for example in April 2004. Since filing his claim for service connection, the Veteran has undergone surgery to repair a torn left rotary cuff. The Veteran has not yet been afforded with a VA examination addressing the nature and etiology of his left shoulder disability. With a currently-diagnosed left shoulder disability and the suggestion of an in-service injury, the Veteran should be provided a VA examination. The Veteran has broadly claimed that service connection is warranted for hypertension. The Board notes that the Veteran was diagnosed with isolated elevated blood pressure in April 2007. Since filing his claim for service connection, the Veteran has consistently received treatment for hypertension. Additionally, the Veteran is service-connected for disabilities such as PTSD. The Veteran has not yet been afforded with a VA examination addressing the nature and etiology of his hypertension disability. With a currently-diagnosed hypertension disability and the presence of both in-service treatment and potentially relevant service-connected disabilities, the Veteran should be provided a VA examination. The Veteran has broadly claimed that service connection is warranted for glaucoma. The existing record does not clearly indicate whether the Veteran indeed has a current glaucoma disability. The Veteran’s treatment records indicate that the Veteran has “glaucoma suspect”. In September 2012, a VA examiner suggested that this was indeed a diagnosis, but opined only that the Veteran’s glaucoma was not caused by diabetes or conjunctivitis. The examiner did not address whether the Veteran’s glaucoma suspect related directly to his active duty service, to include his service in Southwest Asia. The Veteran should be provided with an additional VA examination addressing both whether the Veteran has indeed been diagnosed with a glaucoma disability, and if so, whether such disability directly relates to service or secondarily relates to his service-connected disabilities. The Veteran served in Southwest Asia during the Persian Gulf War, and he has not been afforded an examination addressing the nature and etiology of his claimed fibromyalgia disability. Additionally, the Veteran has claimed that he is prevented from working as a result of his service connected disabilities. As such, the question of TDIU is raised by the record. The matters are REMANDED for the following actions: 1. Schedule the Veteran for VA examinations to determine the nature and etiology of his OSA, diabetes, and left shoulder disability. After reviewing the Veteran’s electronic claims file and describing the nature of the Veteran’s disability, the examiner should address whether it is at least as likely as not (that is, a 50 percent probability or greater) that the Veteran’s OSA, diabetes, and left shoulder disability began during or was otherwise caused by his military service. A complete rationale should be provided. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his hypertension disability. After reviewing the Veteran’s electronic claims file and describing the nature of the Veteran’s disability, the examiner should address whether it is at least as likely as not (that is, a 50 percent probability or greater) that the Veteran’s hypertension: (a.) began during or was otherwise caused by his military service, or; (b.) was caused or aggravated (that is, permanently increased in severity beyond the natural progress of the disorder) by any of his service connected disabilities, to include PTSD. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed glaucoma disability. After reviewing the Veteran’s electronic claims file and describing the nature of the Veteran’s disability, to include addressing whether the Veteran’s “glaucoma suspect” constitutes a disability, the examiner should address whether it is at least as likely as not (that is, a 50 percent probability or greater) that the Veteran’s glaucoma: (a.) began during or was otherwise caused by his military service, or; (b.) was caused or aggravated (that is, permanently increased in severity beyond the natural progress of the disorder) by any of his service connected disabilities. 4. Schedule the Veteran for a Gulf War examination to address the Veteran’s claimed fibromyalgia. After reviewing the Veteran’s electronic claims file, the examiner should address whether the Veteran has had fibromyalgia at any time during the appeal period. (a.) If the Veteran has a diagnosis of fibromyalgia, is it at least as likely as not (50 percent probability or greater) that the condition is related to his period of active service, including time served in the Gulf War? (b.) If the Veteran does not have fibromyalgia, does the Veteran have a cluster of signs or symptoms such as fibromyalgia, that are signs or symptoms of an undiagnosed illness? If so, the examiner should determine whether the Veteran has objective indications of the symptoms or signs that are identified as due to an undiagnosed illness. (c.) If the Veteran’s symptoms are due to a known disease or injury, the examiner should determine whether the underlying disease or injury was incurred during service. (d.) In this regard, is it at least as likely as not (50 percent probability or greater) that such diagnosed illness is related to active service or any incident of service? MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.A. Flynn