Citation Nr: 21066266 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 19-00 543 DATE: October 29, 2021 ORDER New and material evidence having been received, the claim of service connection for a right shoulder disability is granted. New and material evidence having been received, the claim of service connection for a low back disability is granted. New and material evidence having been received, the claim of service connection for a left knee disability is granted. New and material evidence having been received, the claim of service connection for a left ankle disability is granted. Service connection for a right shoulder disability is granted. Service connection for a low back disability is granted. Service connection for a left knee disability is granted. Service connection for a left ankle disability is granted. Entitlement to a disability rating of 20 percent, but no more, for right knee arthritis is granted on and after October 8, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a disability rating of 30 percent for right knee instability is granted on and after October 8, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a disability rating of 70 percent for depressive disorder with secondary somatic symptoms disorder is granted on and after December 20, 2017, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted on and after July 2, 2020. FINDINGS OF FACT 1. The Veteran's claim for service connection for a right shoulder disability was denied in a November 2013 rating decision on the basis that the evidence failed to establish a nexus to service. She was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 2. Evidence received since the November 2013 rating decision raises a substantial possibility of substantiating the claim of service connection for a right shoulder disability. 3. The Veteran's claim for service connection for a low back disability was denied in a September 2011 rating decision on the basis that the evidence failed to establish a nexus to service. She was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 4. Evidence received since the September 2011 rating decision raises a substantial possibility of substantiating the claim of service connection for a low back disability. 5. The Veteran's claim for service connection for a left knee disability was denied in a May 2002 rating decision on the basis that the evidence failed to establish a nexus to service. She was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 6. Evidence received since the May 2002 rating decision raises a substantial possibility of substantiating the claim of service connection for a left knee disability. 7. The Veteran's claim for service connection for left ankle overuse syndrome was denied in an April 1998 rating decision on the basis that the evidence failed to establish a current disability or a nexus to service. She was notified of this decision, did not timely disagree with it or submit new and material evidence within one year of it, and it became final. 8. Evidence received since the April 1998 rating decision raises a substantial possibility of substantiating the claim of service connection for a left ankle disability. 9. The probative evidence of record is at least in equipoise as to whether the Veteran's right shoulder disability is caused by her service-connected instability and arthritis of the right knee. 10. The probative evidence of record is at least in equipoise as to whether the Veteran's low back disability is caused by her service-connected instability and arthritis of the right knee. 11. The probative evidence of record is at least in equipoise as to whether the Veteran's left knee disability is caused by her service-connected instability and arthritis of the right knee. 12. The probative evidence of record is at least in equipoise as to whether the Veteran's left ankle disability is caused by her service-connected instability and arthritis of the right knee. 13. For the period on appeal, the Veteran's right knee arthritis was manifested as symptoms analogous to impairment of the tibia and fibula with moderate knee disability and severe recurrent subluxation or lateral instability, but not ankylosis, limitation of flexion to 45 degrees, limitation of extension to 10 degrees, or dislocated or removed semilunar cartilage. 14. Throughout the period on appeal, the Veteran's depressive disorder with secondary somatic symptoms disorder has been manifested by occupational and social impairment with deficiencies in most areas, but not total occupational and total social impairment. 15. The Veteran's service-connected disabilities have met the percentage requirements for the award of a schedular TDIU, and the evidence indicates that the nature and severity of these disabilities have prevented her from performing gainful employment for which her education and occupational experience would otherwise qualify her since July 2, 2020. CONCLUSIONS OF LAW 1. The November 2013 rating decision is final with regard to the issue of service connection for a right shoulder disability. New and material evidence sufficient to reopen the claim of service connection for a right shoulder disability has been received. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.104, 3.156, 19.52, 20.1103 (2021). 2. The September 2011 rating decision is final with regard to the issue of service connection for a low back disability. New and material evidence sufficient to reopen the claim of service connection for a low back disability has been received. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 19.52, 20.1103. 3. The May 2002 rating decision is final with regard to the issue of service connection for a left knee disability. New and material evidence sufficient to reopen the claim of service connection for a left knee disability has been received. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 19.52, 20.1103. 4. The April 1998 rating decision is final with regard to the issue of service connection for left ankle overuse syndrome. New and material evidence sufficient to reopen the claim of service connection for a left ankle disability has been received. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 19.52, 20.1103. 5. With resolution of reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for a right shoulder disability have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2021). 6. With resolution of reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for a low back disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 7. With resolution of reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 8. With resolution of reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for a left ankle disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 9. With resolution of reasonable doubt in the Veteran's favor, on and after October 8, 2014, the criteria for a rating of 20 percent, but no higher, for right knee arthritis have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5262 (2020). 10. With resolution of reasonable doubt in the Veteran's favor, on and after October 8, 2014, the criteria for a rating of 30 percent for right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2020). 11. With resolution of reasonable doubt in the Veteran's favor, on and after December 20, 2017, the criteria for a disability rating of 70 percent, but no higher, for depressive disorder with secondary somatic symptoms disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9421 (2021). 12. With resolution of reasonable doubt in the Veteran's favor, the criteria for the award of a TDIU have been met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from August 1997 to October 1997. The Veteran testified before the undersigned Veterans Law Judge during a June 2021 hearing and a transcript is of record. These matters are on appeal from April 2015, March 2018, and October 2018 rating decisions. As the undersigned Veterans Law Judge indicated on the record during the June 2021 hearing, because the Veteran contends that she is unemployable as a result of her service-connected psychiatric and orthopedic disabilities, the Board finds that the issue of entitlement to a TDIU has been raised in connection with the claims on appeal for increased ratings. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor her attorney have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). New and Material Evidence In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured to that claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence is neither cumulative nor redundant of evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). However, evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343, 1347 (Fed. Cir. 2000). In deciding whether new and material evidence has been submitted, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is generally "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Until the Veteran meets her threshold burden of submitting new and material evidence sufficient to reopen her claim of entitlement to service connection, the benefit of the doubt doctrine does not apply. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). 1. Right Shoulder Disability The Veteran contends that she has a right shoulder disability that is etiologically related to her active duty service. The Veteran was denied service connection for a right shoulder disability in a November 2013 rating decision. She did not submit a Notice of Disagreement (NOD) or new and material evidence within one year of the rating decision. Therefore, the November 2013 rating decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.204, 20.302, 20.1103 (2021). The basis for the November 2013 denial was a lack of evidence of a nexus to service. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in November 2013, that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has a right shoulder disability as a result of active duty service. The evidence that was of record at the time of the November 2013 rating decision included the Veteran's service treatment records and VA treatment records. Since the November 2013 rating decision, the Veteran has provided a July 2021 medical opinion by a private orthopedic surgeon. The orthopedic surgeon opined that it is at least as likely as not that the Veteran's current right shoulder disability was caused by her service-connected right knee disabilities. As the record now contains more evidence pertinent to the issue of nexus to service than it did in November 2013, the Board finds that new and material evidence has been received which pertains to previously unestablished facts necessary to support the claim. As this evidence raises a reasonable possibility of substantiating the claim, satisfying the criteria of 38 C.F.R. § 3.156(a) for new and material evidence, the claim is reopened. 2. Low Back Disability The Veteran contends that she has a low back disability that is etiologically related to her active duty service. The Veteran was denied service connection for a low back disability in a September 2011 rating decision. She did not submit a NOD or new and material evidence within one year of the rating decision. Therefore, the September 2011 rating decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.204, 20.302, 20.1103. The basis for the September 2011 denial was a lack of evidence of a nexus to service. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in September 2011, that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has a low back disability as a result of active duty service. The evidence that was of record at the time of the September 2011 rating decision included the Veteran's service treatment records, VA treatment records, private treatment records, and a VA examination report. Since the September 2011 rating decision, the Veteran has provided a July 2021 medical opinion by a private orthopedic surgeon. The orthopedic surgeon opined that it is at least as likely as not that the Veteran's current low back disability was caused by her service-connected right knee disabilities. As the record now contains more evidence pertinent to the issue of nexus to service than it did in September 2011, the Board finds that new and material evidence has been received which pertains to previously unestablished facts necessary to support the claim. As this evidence raises a reasonable possibility of substantiating the claim, satisfying the criteria of 38 C.F.R. § 3.156(a) for new and material evidence, the claim is reopened. 3. Left Knee Disability The Veteran contends that she has a left knee disability that is etiologically related to her active duty service. The Veteran was denied service connection for a low back disability in a May 2002 rating decision. She did not submit a NOD or new and material evidence within one year of the rating decision. Therefore, the May 2002 rating decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.204, 20.302, 20.1103. The basis for the May 2002 denial was a lack of evidence of a nexus to service. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in May 2002, that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has a left knee disability as a result of active duty service. The evidence that was of record at the time of the May 2002 rating decision included the Veteran's service treatment records. Since the May 2002 rating decision, the Veteran has provided a July 2021 medical opinion by a private orthopedic surgeon. The orthopedic surgeon opined that it is at least as likely as not that the Veteran's current left knee disability was caused by her service-connected right knee disabilities. As the record now contains more evidence pertinent to the issue of nexus to service than it did in May 2002, the Board finds that new and material evidence has been received which pertains to previously unestablished facts necessary to support the claim. As this evidence raises a reasonable possibility of substantiating the claim, satisfying the criteria of 38 C.F.R. § 3.156(a) for new and material evidence, the claim is reopened. 4. Left Ankle Disability The Veteran contends that she has a left ankle disability that is etiologically related to her active duty service. The Veteran was denied service connection for left ankle overuse syndrome in an April 1998 rating decision. She did not submit a NOD or new and material evidence within one year of the rating decision. Therefore, the April 1998 rating decision is final. 38 U.S.C. § 7105(b)(1); 38 C.F.R. §§ 20.204, 20.302, 20.1103. The basis for the April 1998 denial was a lack of evidence of a current disability or a nexus to service. The question is thus whether the Veteran has submitted or VA has otherwise received evidence that was not before the adjudicator in April 1998, that is neither redundant nor cumulative, and that raises a reasonable possibility of substantiating a claim that the Veteran currently has a left ankle disability as a result of active duty service. The evidence that was of record at the time of the April 1998 rating decision included the Veteran's service treatment records and a VA examination report. Since the April 1998 rating decision, the Veteran has testified during the June 2021 hearing as to her current left ankle symptoms and their etiology. As the record now contains more evidence pertinent to the issues of a current disability and a nexus to service than it did in April 1998, the Board finds that new and material evidence has been received which pertains to previously unestablished facts necessary to support the claim. As this evidence raises a reasonable possibility of substantiating the claim, satisfying the criteria of 38 C.F.R. § 3.156(a) for new and material evidence, the claim is reopened. 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. § 1110; 38 C.F.R. § 3.303. 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The presumption of service connection applies to anyone who served on active duty for 90 days of active, continuous service. 38 C.F.R. § 3.307(a)(1); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Post-service development of arthritis to a degree of 10 percent within one year from the date of termination of such service, establishes a rebuttable presumption that the disease was incurred in service. 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309 (2021). Because the Veteran served on active duty for less than 90 days, this presumption does not apply. Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Right Shoulder Disability The Veteran contends that her right shoulder disability was caused or aggravated by her service-connected right knee instability and arthritis. During a May 2012 VA treatment appointment, the Veteran reported onset of right shoulder pain about one month prior, when she started to work at a health care facility with duties including lifting and turning patients. During a March 2013 VA treatment appointment, the Veteran reported that she had fallen about three weeks prior and caught herself with her hands, after which her right shoulder pain worsened from intermittent to nearly constant. An MRI of the right shoulder in April 2013 noted edema/possible nondisplaced fracture involving the anterior proximal right humerus, a partial tear of the distal supraspinatus muscle/tendon, and degenerative changes involving the AC joint and degenerative spur involving the inferior acromion. During a January 2016 visit to a VA facility for emergency treatment, the Veteran reported falling onto her outstretched hands as a result of her right knee giving out, with the majority of force on her right upper extremity and right shoulder pain since then. During an August 2018 visit to a VA facility for emergency treatment, the Veteran reported that her right knee again gave out and this time she fell down stairs, with right shoulder pain since then. The Veteran was afforded a VA examination in March 2019. The clinician diagnosed right shoulder impingement syndrome, acromioclavicular joint osteoarthritis, and a partial tear of the distal supraspinatus tendon. The clinician provided an opinion that was unfavorable to the Veteran's claim, as did other VA clinicians in April 2019 and July 2019, but these opinions focused on the possibility of a direct relationship between the Veteran's right knee disabilities and her right shoulder disability without addressing the Veteran's contention, which is that her right knee repeatedly gives out, which has caused her to fall, leading to shoulder injuries. Because these opinions do not address the Veteran's contentions regarding service connection, these opinions are of no probative value and will play no role in the Board's analysis. During the June 2021 hearing, the Veteran testified that she injured her right shoulder in 2013 because her right knee gave out and she fell. The Board notes that the Veteran worked as a nurse until July 2020; she is thus competent to provide a medical opinion. The Veteran has submitted a July 2021 medical opinion by a private orthopedic surgeon, who opined that her current right shoulder disability was a "direct result" of her 2013 fall and that the fall was caused by subluxation of her right knee. The record contains VA and private medical opinions with regard to this claim. As stated above, the VA opinions are inadequate. The Veteran's VA treatment records note repeated falls as a result of her right knee giving way and specifically note worsening of right shoulder symptoms after the 2013 fall. The private orthopedic surgeon and the Veteran herself have provided opinions favorable to her claim and, as stated above, the Veteran is competent to provide a medical opinion. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran's favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran's right shoulder disability was caused or aggravated, at least in part, by her service-connected right knee disabilities. Accordingly, the Board finds that granting service connection for a right shoulder disability is the decision that is the most consistent with VA's policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303 (a), 3.310. 6. Low Back Disability The Veteran contends that her low back disability was caused or aggravated by her service-connected right knee instability and arthritis. A private x-ray report from March 1994, three years prior to the Veteran's active duty service, noted mild scoliosis of the lumbar spine. Additional regulations apply when the evidence indicates that a disability may have existed prior to the Veteran's active duty service and none of the medical opinions of record have addressed the questions required by those regulations. However, because the record shows diagnoses of other low back disabilities and those disabilities are the basis of the Board's grant of service connection, the Board finds that a remand to address those questions is not warranted. The Veteran was afforded a VA examination in November 2010. The clinician diagnosed lumbar scoliosis and opined that it was less likely than not that it was caused by her service-connected right knee disabilities, but provided no opinion with regard to aggravation. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). This examination report is therefore of no probative value and will play no role in the Board's analysis. The Veteran was afforded an additional VA examination in January 2018. The clinician diagnosed degenerative arthritis of the spine and facet arthropathy; the clinician opined that it was less likely than not that these disabilities were caused by her service-connected right knee disabilities, but provided no opinion with regard to aggravation. As stated above, to be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio, 30 Vet. App. 74. This examination report is therefore also of no probative value and will play no role in the Board's analysis. During an August 2018 VA treatment appointment, the Veteran reported muscle spasms in her lower back after a fall caused by her right knee giving out. The Veteran has submitted a July 2021 medical opinion by a private orthopedic surgeon, who opined that her current low back disability was caused by prolonged limping as a result of her service-connected right knee disabilities. The orthopedic surgeon provided a thorough rationale for this opinion. The record contains VA and private medical opinions with regard to this claim. As stated above, the VA opinions are inadequate. The private orthopedic surgeon has provided an opinion favorable to her claim and supported it with a thorough rationale. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran's favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran's low back disability was caused or aggravated, at least in part, by her service-connected right knee disabilities. Accordingly, the Board finds that granting service connection for a low back disability is the decision that is the most consistent with VA's policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303 (a), 3.310. 7. Left Knee Disability The Veteran contends that her left knee disability was caused or aggravated by her service-connected right knee instability and arthritis. Because the Veteran's right knee disabilities are service-connected, she has been afforded several VA examinations with regard to knee symptoms, but most of them focused on the right knee with some incidental left knee findings. The only VA examination that directly addressed the Veteran's left knee disability and its etiology was in January 2018. The clinician diagnosed a left knee meniscal tear and opined that it was less likely than not that this disability was caused by her service-connected right knee disabilities, but provided no opinion with regard to aggravation. As stated above, to be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio, 30 Vet. App. 74. This examination report is therefore also of no probative value and will play no role in the Board's analysis. During an August 2018 VA treatment appointment, the Veteran reported muscle spasms in her lower back after a fall caused by her right knee giving out. During the June 2021 hearing, the Veteran testified that her left knee disability was caused by an altered gait due to her right knee symptoms. As stated above, because the Veteran worked as a nurse until July 2020, she is competent to provide a medical opinion. The Veteran has submitted a July 2021 medical opinion by a private orthopedic surgeon, who opined that her current left knee disability was caused by a chronic antalgic gait as a result of her service-connected right knee disabilities. The orthopedic surgeon provided a thorough rationale for this opinion. The record contains VA and private medical opinions with regard to this claim. As stated above, the VA opinions are inadequate. The private orthopedic surgeon has provided an opinion favorable to her claim and supported it with a thorough rationale. The Veteran herself has also provided an opinion favorable to her claim and, as stated above, the Veteran is competent to provide a medical opinion. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran's favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran's left knee disability was caused or aggravated, at least in part, by her service-connected right knee disabilities. Accordingly, the Board finds that granting service connection for a left knee disability is the decision that is the most consistent with VA's policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303 (a), 3.310. 8. Left Ankle Disability The Veteran contends that her left ankle disability was caused or aggravated by her service-connected right knee instability and arthritis. The Veteran has not been afforded a VA examination for ankle disabilities during the period on appeal. The only VA examination that discussed the Veteran's ankle symptoms was in March 1998, sixteen years prior to the period on appeal. The clinician found that the Veteran's ankles were normal. During the June 2021 hearing, the Veteran testified that her left ankle was in constant pain and that she had to wear a brace "because it swells up and gives out on [her] also now." She testified that this disability was caused by an altered gait due to her right knee symptoms. As stated above, because the Veteran worked as a nurse until July 2020, she is competent to provide a medical opinion. The only medical opinion of record is that of the Veteran, which she is competent to provide and which is favorable to her claim. Although she did not diagnose herself with any specific left ankle disability, she competently and credibly reported pain and functional impairment. "[P]ain in the absence of a presently-diagnosed condition can cause functional impairment." Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran's favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran has a left ankle disability and that it was caused or aggravated, at least in part, by her service-connected right knee disabilities. Accordingly, the Board finds that granting service connection for a left ankle disability is the decision that is the most consistent with VA's policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303 (a), 3.310. Increased Rating 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 (2021). 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. "Staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claim for a higher initial evaluation for the Veteran's depressive disorder with secondary somatic symptoms disorder, the Board has considered all evidence of severity from the effective date for the award of service connection for that claim. Fenderson v. West, 12 Vet. App. 119 (1999). With regard to the right knee arthritis and instability claims, when entitlement to compensation has already been established and an increased rating is at issue, the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed. Hart, at 509; see also 38 U.S.C. § 5110(b)(3) (2012); 38 C.F.R. § 3.400(o)(2) (2019). 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. 9. Right Knee Arthritis 10. Right Knee Instability The Veteran contends that her knee disabilities warrant higher ratings than those currently assigned. They are currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010, for right knee arthritis with a 10 percent rating on and after October 22, 1997, and under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for right knee instability with a 10 percent rating on and after October 1, 2010. VA received the Veteran's claim for an increased rating on October 8, 2014. In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, "pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. In this case, at least the minimum compensable rating has been in effect for these disabilities during the entire appeal period. Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that are more favorable to the Veteran will be applied. Prior to the amendment, Diagnostic Code 5010 provided for rating as degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 provides, when limitation of motion is noncompensable under the appropriate Diagnostic Code, for a 10 percent rating for each major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. For rating purposes, the knee is considered a major joint. 38 C.F.R. § 4.45. As the Veteran is already in receipt of a 10 percent rating based on arthritis throughout the period on appeal, an increased rating under Diagnostic Code 5003 is not applicable. As the Veteran's knee disabilities already include a rating based on arthritis throughout the period on appeal, further discussion of Diagnostic Code 5010 under the prior criteria is not warranted. After the amendment, Diagnostic Code 5010 provides for rating as limitation of motion, dislocation, or other specified instability under the affected joint. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5010). Limitation of flexion of the leg is evaluated as follows: flexion limited to 15 degrees (30 percent); flexion limited to 30 degrees (20 percent); flexion limited to 45 degrees (10 percent); and flexion limited to 60 degrees (noncompensable). 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg is evaluated as follows: extension limited to 45 degrees (50 percent); extension limited to 30 degrees (40 percent); extension limited to 20 degrees (30 percent); extension limited to 15 degrees (20 percent); extension limited to 10 degrees (10 percent); and extension limited to 5 degrees (noncompensable). 38 C.F.R. § 4.71a, Diagnostic Code 5261. For VA purposes, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. There are additional Diagnostic Codes that apply to knee disorders. 38 C.F.R. § 4.71a, Diagnostic Code 5256 (2020) pertains to ankylosis of the knee. Prior to the amendment, recurrent subluxation or lateral instability of the knee was evaluated as follows: severe (30 percent); moderate (20 percent); and slight (10 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. After the amendment, a compensable rating for knee subluxation requires that subluxation be the result of a ligament tear and a rating in excess of 10 percent for patellar instability requires that instability be recurrent after surgical repair. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Because the record contains no evidence of surgical repair, these criteria are less favorable to the Veteran and the old criteria will be used throughout the period on appeal. Meniscal conditions are evaluated as follows: dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint (20 percent); and symptomatic removal of semilunar cartilage (10 percent). 38 C.F.R. § 4.71a, Diagnostic Codes 5258 and 5259 (2020). Prior to the amendment, impairment of the tibia and fibula were evaluated as follows: nonunion with loose motion, requiring a brace (40 percent); malunion with marked knee or ankle disability (30 percent); malunion with moderate knee or ankle disability (20 percent); and malunion with slight knee or ankle disability (10 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2020). After the amendment, impairment of the tibia and fibula are evaluated as follows: nonunion with loose motion, requiring a brace (40 percent); malunion (evaluate under whichever of Diagnostic Codes 5256, 5257, 5260, or 5261 results in the highest evaluation); or medial tibial stress syndrome (MTSS) or shin splints (rate between 0 and 30 percent depending on the length and efficacy of treatment). Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5262). A June 2014 VA x-ray of the Veteran's right knee found no significant bony abnormality. A December 2014 VA MRI of the Veteran's right knee found no acute findings, no significant interval change since November 2012, and intact menisci and cruciates. The Veteran was afforded a VA examination for knee and lower leg disabilities in April 2015. The Veteran reported that her knee gave out and buckled at random times and that she wore a knee sleeve and brace whenever she was on her feet for an extended period, such as at work. She also reported constant pain, with flare ups of increased pain after buckling that usually took thirty to sixty minutes to resolve. She reported that, during flare ups, she had to stop and sit or lay down because she could not walk. However, the clinician made no attempt to quantify the limitation of range of motion that would occur during flare ups or after repetition over time because the examination did not take place under those circumstances. The United States Court of Appeals for Veterans Claims (Court) has held that there must be an adequate rationale for declining to provide an opinion with regard to the functional impact of repetitive use over time or flare ups and that this type of rationale is insufficient. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board therefore finds that the April 2015 examination report is inadequate for rating purposes and of no probative value with regard to range of motion; it will play no role in the Board's analysis as far as range of motion is concerned. However, the Board notes that the clinician also found no instability, no tibial or fibular impairment, and no meniscal condition. A July 2015 VA x-ray of the Veteran's right knee found mild degenerative narrowing of the medial femorotibial compartment and that this was similar to the June 2014 x-ray. In January 2016, the Veteran sought emergency treatment at a VA facility because her right knee had been giving out with greater frequency; she denied any specific precipitating factor. She reported that it was giving out about twice a day. An x-ray at this time showed no acute fracture or dislocation, minimal joint space narrowing of the medial compartment unchanged since July 2015, and no effusion. Another x-ray five days later was radiographically unremarkable other than stable mild decreased height of the medial femoral tibial compartment. A February 2016 VA MRI of the Veteran's right knee found possible slight evulsion of the very anterior root of the anterior horn of the lateral meniscus, but an otherwise intact lateral and medial meniscus. The MRI also found some mild generalized edema of the soft tissues around the right knee, particularly adjacent to the medial patellar retinaculum. The radiologist expressed suspicion of mild injury of the medial patella retinaculum without any tear. The Veteran was afforded an additional VA examination in January 2018. The clinician diagnosed a right knee meniscal tear in 2017 as well as instability and degenerative arthritis. The Veteran did not report flare ups, but reported functional impairment in the form of inability to perform impact activity such as running and jumping. On examination, range of motion was reported as 0 degrees of extension to 140 degrees of flexion. Pain was noted on both flexion and extension but it did not cause functional loss. There was evidence of pain with weight bearing, but not objective evidence of localized tenderness, pain on palpation, or crepitus. There was no additional loss of motion on repetition. The clinician indicated that the examination was immediately after repetitive use over time and that these circumstances did not significantly limit functional ability. There were no additional factors contributing to disability. There was no muscle atrophy or reduction in muscle strength. There was no ankylosis or history of recurrent subluxation, instability, or effusion. Joint stability testing was normal. There was no tibial or fibular impairment. There was a history of a meniscal tear, with frequent episodes of joint pain. The Veteran reported regularly using a brace for instability. The clinician found that the Veteran's knee disabilities would have no impact on her ability to work. The clinician added that there was pain with passive range of motion and with weight bearing, but it did not result in or cause functional loss, and that there was no pain with non-weight bearing. In August 2018, the Veteran sought emergency treatment at a VA facility because she fell down stairs after her right knee gave out. During a VA treatment appointment later that month, she reported another fall after her knee giving way. During a September 2019 VA treatment appointment, the Veteran reported that her right knee usually gave out about two to eight times a month. During a November 2020 hearing before a Hearing Officer at the Agency of Original Jurisdiction (AOJ), the Veteran reported that she had fallen due to right knee buckling "quite a few times" and that this buckling occurred without warning. She added that she was using crutches because "it went out about three weeks ago and [she had her] brace on and [she couldn't] put pressure on [her] leg." She also reported that her symptoms were continuously worsening, that people helped her to walk around, and that she had episodes every few months in which she "basically" "can't walk at all." The Veteran was afforded an additional VA examination in January 2021. The Veteran reported constant right knee pain, increased with activity, as well as swelling with increased activity and sharp pain with swelling. She also reported that her knee gave out frequently and that she had to wear crutches for extended periods when the knee was swollen (around two months) approximately four times a year. She reported that, during flare ups, her knee swelled and she had to use crutches as described above because she could not bear any weight on her right leg. She reported functional impairment in the form of interference with her ability to work, especially walking and driving to assignments. On examination, range of motion in the was reported as 0 degrees of extension to 120 degrees of flexion. The range of motion did not contribute to functional loss. Pain was noted on extension but did not cause functional loss. There was evidence of pain with weight bearing, but no objective evidence of localized tenderness, pain on palpation, or crepitus. There was no additional loss of range on repetition. The examination was not immediately after repetitive use over time. The clinician found that there would be further loss of functional ability under those circumstances due to pain, but no reduction in range of motion. The examination took place during a flare up, so the range of motion was as described above. Additional factors contributing to disability were decreased movement, weakened movement, swelling, and interference with sitting and standing, all related to pain. Muscle strength was with active movement against some resistance, but less than normal strength, and there was no muscle atrophy. There was no ankylosis and the clinician found no history of recurrent subluxation, effusion, or instability. Anterior, posterior, medial, and lateral stability testing was normal. There was no tibial or fibular impairment. There was a history of a meniscal tear, with frequent episodes of joint pain. The Veteran reported regularly using crutches and constantly using a brace due to arthritis. The clinician found that the Veteran's knee disabilities would have an impact on her ability to work by causing difficulty completing tasks involving walking, standing, or sitting for extended periods of time. The clinician also noted that passive range of motion was the same as active range of motion and that there was no objective evidence of pain on non-weight bearing. During the June 2021 hearing, the Veteran testified that she had to have a cane with her at all times because her knee "will go out or buckle on [her] just without warning now" and that buckling was now a daily occurrence. The Veteran has submitted a July 2021 examination report by a private orthopedic surgeon, who interviewed the Veteran, who reported worsening instability and that her knee would "go out of place" if she turned or pivoted quickly, with her kneecap sliding in the opposite direction, and that when this happened she would almost always fall. She reported a worsening limp and that she had used crutches for several years before switching to a cane at the recommendation of her physical therapist in 2020. She also reported that she could not go down stairs while leading with her right leg because her knee was very likely to "pop out" and that, as a result, she went down one step at a time, leading with her left leg, and holding her foot sideways. She reported pain in specific areas of her knee and increased pain when going from a sitting to a standing position or squatting; she also reported that, when squatting, she could not stand up by herself due to increased pain associated with strengthening the knee. She also reported constant pain and a grinding sensation. She added that one of her children had to assist her at times in going from a sitting to a standing position and that said child was "almost always standing by when she maneuvers stairs." The surgeon found no indication of exaggeration or feigning of symptoms and deemed her responses to be forthright and honest. Based on these reports and the medical evidence of record, the surgeon opined that the Veteran's right knee symptoms were analogous to tibia and fibula impairment resulting in a moderate knee disability and that her instability was "very severe." Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, her right knee instability warrants a 30 percent rating throughout the period on appeal. The Veteran has reported instability on multiple occasions, including seeking treatment for injuries after repeated falls, and the private orthopedic surgeon opined that her instability was very severe. 30 percent is the maximum schedular rating for recurrent subluxation or lateral instability of a knee. The preponderance of the evidence described above also shows that the Veteran's right knee arthritis warrants a separate 20 percent rating under the pre-amendment version of Diagnostic Code 5262. The private orthopedic surgeon opined that her symptoms were best analogized to impairment of the tibia and fibula with moderate knee disability. This is the rating requested by the Veteran's attorney and the record contains no evidence of symptoms nonunion of the tibia and fibula or malunion with marked knee disability. A rating under the amended version of Diagnostic Code 5262 is not warranted because a 30 percent rating requires shin splints that are unresponsive to surgery and a 40 percent rating continues to require nonunion. Any change in Diagnostic Code must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board concludes that the Veteran's right knee arthritis is more closely analogous to impairment of the tibia and fibula, which is rated under Diagnostic Code 5262. As described above, the Veteran's right knee symptoms meet the criteria for a 20 percent rating under Diagnostic Code 5262, but 10 percent is the maximum rating under Diagnostic Code 5010. Service connection for a disability is not severed when the Diagnostic Code associated with it is changed to more accurately determine the benefit to which a veteran may be entitled. Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). The change in Diagnostic Code is not improper because the criteria set forth in Diagnostic Code 5262 are more analogous to the nature of the Veteran's disability and do not result in a reduction in benefits. The Board also finds that there are no other Diagnostic Codes to which the Veteran's right knee symptoms would be more closely analogous than Diagnostic Code 5262 that would result in a higher rating. The preponderance of the evidence also shows that the Veteran's right knee disabilities were not manifested by ankylosis, dislocated or removed meniscal cartilage, limitation of flexion to 45 degrees or less, or limitation of extension to 10 degrees or less during this period. The Board has considered the Veteran's lay statements. The Veteran is competent to report her own observations with regard to the symptoms of her knee disabilities and her descriptions are credible. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has accepted those statements as the basis for granting increased ratings as assigned above. However, nothing in the Veteran's lay statements provides a basis for assigning higher ratings than those assigned herein under any Diagnostic Code pertaining to musculoskeletal disabilities of the knee. In addition, the Board considered whether higher ratings are warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. There is nothing to indicate that the Veteran's pain or any other DeLuca factor causes functional impairment equivalent to the criteria for ratings in excess of those already in effect or assigned herein. Because the Board considered the applicable ratings under every Diagnostic Code pertaining to musculoskeletal disabilities of the knee, the Board finds that there are no other potentially applicable Diagnostic Codes by which higher ratings can be assigned. 11. Depressive Disorder with Secondary Somatic Symptoms Disorder The Veteran contends that her depressive disorder with secondary somatic symptoms disorder warrants a higher rating than that currently assigned. It is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9421, for somatic symptom disorder, with a 30 percent rating on and after December 20, 2017. The full period of service connection is on appeal. Under 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 provides that a 30 percent evaluation is warranted for 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; and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, occupation, or own name. Id. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. See VazquezClaudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). VA 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. 38 C.F.R. § 4.126 (a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). The Veteran was afforded a VA examination by a psychologist in March 2018. The psychologist diagnosed depressive disorder due to another medical condition with mixed features and somatic symptoms disorder with predominant pain. The Veteran reported that she had been divorced from her second spouse since 2012, had been separated from him since 2010, and was not currently involved in a significant relationship. She reported that she lived with her sons and had good relationships with them. She reported working as a Licensed Practical Nurse (LPN). She also reported symptoms including social withdrawal, decreased energy and motivation, sadness, worry, and panic attacks. She did not specify the frequency of her panic attacks but reported that they included shortness of breath, racing thoughts, and nervousness. The psychologist listed the Veteran's symptoms for rating purposes as depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran was oriented, she demonstrated sufficient attention and concentration for the evaluation, she showed intact recent and remote memory, her language comprehension was sufficient for testing, her mood was "reasonably positive," her affect was congruent, her speech was linear, purposeful, and within normal limits in rate and volume, little spontaneous speech was noted but she responded appropriately to questions, her thought processes appeared to be within normal limits, her mental computation abilities and abstract reasoning were within normal limits, there were no apparent psychotic thoughts, hallucinations, delusions, or obsessions, she did not manifest a preoccupation with violence, homicidal ideation, or suicidal ideation, her associations were grossly intact and her judgment and insight were within normal limits. The psychologist characterized the Veteran's overall level of occupational and social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which is consistent with a 30 percent rating. In a September 2018 statement, the Veteran reported her symptoms as lack of appetite including not eating for two to three days at a time, inability to sleep for more than one and a half hours for weeks at a time and then sleeping for twelve to eighteen hours, having no real relationships with her coworkers, going straight to bed after work due to feeling overwhelmed, occasionally lacking the energy to shower when getting home, having no friends, talking to no one on a daily basis other than the people she lived with (two children, the oldest child's fiancée, and a grandchild), sometimes only speaking to her youngest child "and that is just to make sure he is doing what he needs to do," not leaving her house on days off and sometimes rarely leaving her bedroom, "[m]ind always running in 50 different directions at one time," sadness, anxiety, worry, and anger. She also attributed being single to "insecurity because depression anxiety and pain" and reported missing work "because [she] can't get out of bed, because [she feels] so bad." In an October 2018 statement, the Veteran's attorney requested a 70 percent rating based on this statement. The Veteran has submitted a June 2021 examination report by a private psychologist, who characterized her overall level of occupational and social impairment as occupational and social impairment with deficiencies in most areas, which is consistent with a 70 percent rating. The psychologist listed the Veteran's symptoms for rating purposes as depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. In a September 2021 statement, the Veteran's attorney requested a 70 percent rating based on this examination report. During the June 2021 hearing, the Veteran testified that she had no friends, was isolated from her family, and lived "in a camper." She also testified that she had not worked in nearly a year and that, when she was working, she felt overwhelmed from being around people. She reported not interacting with her children or grandchildren, but also testified that she sometimes spent time at her parents' house, albeit while laying on a couch or recliner. During the July 2021 examination by a private orthopedic surgeon discussed in connection with the knee claims above, the Veteran clarified that she continues to live with one of her children. Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, her psychiatric symptoms and overall disability picture warrant an evaluation of 70 percent for depressive disorder with secondary somatic symptoms disorder throughout the period on appeal. During that period, the record contains evidence of near-continuous panic or depression, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. For these reasons, the Board finds that Veteran's symptoms most nearly approximate those that warrant a 70 percent rating throughout the period on appeal. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9421. This is also the rating requested by the Veteran's attorney. The Board does not, however, find the criteria for a 100 percent evaluation are more nearly approximated by the Veteran's symptoms at any point during the period on appeal. The record contains evidence of intermittent inability to perform activities of daily living, which is one of the symptoms listed in the criteria for a 100 percent rating. However, even the constant presence of some symptoms listed in the criteria for a 100 percent rating would be insufficient because the overall guiding criterion for a 100 percent rating is that both total occupational and total social impairment be present. 38 C.F.R. § 4.130; see, e.g., Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). In this case, the Veteran's symptoms have not been shown to be so severe that she has both total occupational and total social impairment. "Total" is defined as "whole, not divided; full; complete," and "utter, absolute." Black's Law Dictionary, 1498 (7th ed. 1999). Although the Board has found total occupational impairment for part of the period on appeal by granting a TDIU below, total social impairment is not shown. The Veteran has been able to maintain some personal relationships, specifically with her parents, children, and grandchild. The Board acknowledges that these relationships are sometimes strained or distant, but that is reflected in the current 70 percent rating for "deficiencies in most areas," the criteria for which include inability to establish and maintain effective relationships and difficulty in adapting to stressful circumstances including work or a worklike setting. Because the Veteran is not totally socially impaired, a 100 percent rating is not warranted. The Board also notes that many of the Veteran's reported symptoms throughout the period on appeal are included among those specifically contemplated in the General Rating Formula for Mental Disorders, pursuant to which a 70 percent disability rating has been assigned. See 38 C.F.R. § 4.130. Importantly, the Board notes that symptoms noted in the rating schedule 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran's extent of occupational and social impairment. Accordingly, the existence and severity of the Veteran's psychiatric symptoms are adequately contemplated by the 70 percent rating criteria. As noted above, many of the symptoms are specifically listed in the General Rating Formula for Mental Disorders, and the others are common psychiatric symptoms that-while not specifically listed-are comparable indicators of the type of occupational and social impairment contemplated in the Rating Formula. The Board has also considered the Veteran's assertions, which she is competent to provide. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The lay evidence is also credible. The symptoms described in those lay statements comport with the 70 percent rating that has now been assigned. However, these lay statements do not provide any basis upon which to assign a higher rating because they do not reflect total social impairment. In sum, the Board finds that, resolving reasonable doubt in the Veteran's favor, her impairment due to depressive disorder with secondary somatic symptoms disorder has been most consistent with a 70 percent disability rating throughout the period on appeal. 12. TDIU The Veteran contends that her service-connected disabilities render her unemployable and that she last worked full-time on July 1, 2020. She reports that her knee symptoms prevented her from performing her duties as a nurse and that her mental health was also deteriorating. VA will grant a total disability rating when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from securing and following substantially gainful employment consistent with her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The term "substantially gainful occupation" is not defined in the rating schedule. Rather, the Court in Ray v. Wilkie, found the phrase has two components: an economic one and a noneconomic one. 31 Vet. App. 58 (2019). In assessing the Veteran's ability to secure and follow a substantially gainful occupation, the Board is to consider the Veteran's history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Id. The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the purposes meeting the requirement of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16 (a). Because the Veteran was employed full-time prior to July 2, 2020, a TDIU is not warranted for that period. The Veteran's combined disability rating on and after July 2, 2020, after the increased ratings granted above, is 90 percent: her depressive disorder with secondary somatic symptoms disorder is rated 70 percent disabling, her right knee instability is rated 30 percent disabling, her right knee arthritis is rated 20 percent disabling, and her bilateral pes planus is rated 10 percent disabling. 38 C.F.R. § 4.25 (2021). The criteria for consideration of a schedular TDIU are therefore met on and after July 2, 2020. The Board has described the symptoms of the Veteran's service-connected psychiatric and right knee disabilities in detail above. Prior to July 2, 2020, the Veteran was employed as a nurse, and the record does not show any recent employment or training other than in nursing. The January 2021 VA examiner found that the Veteran's right knee disabilities would cause difficulty completing tasks involving walking, standing, or sitting for extended periods of time. The symptoms of the Veteran's service-connected psychiatric disability include near continuous panic or depression affecting the ability to function independently, appropriately and effectively, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. When taken together, difficulties with walking, standing, sitting, interpersonal interaction, and hygiene effectively preclude employment in the nursing field, which is the only field for which the record contains any evidence of recent experience or training. The Board therefore finds that the evidence is at least evenly balanced as to whether the Veteran's service-connected disabilities have rendered her unemployable under the applicable regulations since July 2, 2020. As reasonable doubt must be resolved in favor of the Veteran, entitlement to a TDIU is warranted on and after July 2, 2020. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ryan Frank, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.