Citation Nr: 21075075 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 17-12 610 DATE: December 17, 2021 ORDER Entitlement to a rating in excess of 20 percent for degenerative disc disease of the lumbar spine is denied. Entitlement to a rating in excess of 10 percent for right knee patellofemoral syndrome with instability is denied. Entitlement to a rating in excess of 10 percent for seasonal allergic rhinitis is denied. Entitlement to an increased rating for hypertension, rated as noncompensably disabling prior to September 28, 2021, and 10 percent disabling thereafter, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) by reason of service-connected disabilities is granted as of May 29, 2020. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's degenerative disc disease of the lumbar spine did not manifest by forward flexion of 60 degrees or less, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-up, ankylosis, incapacitating episodes due to intervertebral disc syndrome or associated bowel or bladder impairments. 2. Throughout the period on appeal, the Veteran's right knee patellofemoral syndrome with instability was manifested by painful motion, flexion that was limited to, at worst, 65 degrees and normal extension even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; without a prescribed knee brace or assistive device, effusion, ankylosis, impairment of the tibia and fibula, or genu recurvatum. 3. Throughout the period on appeal, the Veteran's allergic rhinitis manifests in greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side without polyps. 4. For the appeal period prior to September 28, 2021, the Veteran's hypertension required continuous medication for control without diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. 5. For the appeal period beginning on September 28, 2021, the Veteran's hypertension required continuous medication for control with no evidence of diastolic pressure of predominantly 110 or more, a history of diastolic pressure of predominantly 110 or more or by systolic pressure of predominantly 200 or more. 6. As of May 29, 2020, the Veteran's service-connected disabilities, when evaluated in association with her education and occupational experience, have rendered her unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for degenerative disc disease of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.71a, Diagnostic Code 5242. 2. The criteria for a rating in excess of 10 percent for patellofemoral syndrome of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.27, 4.40, 4.45, 4.71a, Diagnostic Codes 5014, 5257. 3. The criteria for a rating in excess of 10 percent for seasonal allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.97, Diagnostic Code 6522. 4. The criteria for an increased rating for hypertension, rated as noncompensably disabling prior to September 28, 2021, and 10 percent disabling thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1 4.14, 4.104, Diagnostic Code 7101. 5. The criteria for a TDIU have been met as of May 29, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2003 to January 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions in October 2011 and April 2012 issued by the Department of Veterans' Affairs (VA) Regional Office (RO) in Reno, Nevada. The Veteran perfected a timely appeal to those decisions. On January 6, 2021, the Veteran testified in a virtual hearing before the undersigned Veterans Law Judge. A hearing transcript will be associated with the record. In April 2021, the Board remanded the case to the RO for further evidentiary development. Specifically, the matters were remanded to obtain the Veteran's updated VA treatment records and conduct VA examinations to determine the current severity of the Veteran's lumbar spine degenerative disc disease, right knee patellofemoral syndrome with instability, allergic rhinitis and hypertension. Updated VA treatment records were associated with the record and a May 2021 letter requested that the Veteran complete an appropriate authorization form to allow VA to obtain treatment records on her behalf. VA examinations were conducted in October 2021. Following the requested development, a supplemental statement of the case (SSOC) was issued in October 2021. The Board therefore determines that there has been substantial compliance with its previous remand. In an October 2021 rating decision, the agency of original jurisdiction (AOJ) granted a 10 percent rating for hypertension, effective September 28, 2021. It also awarded a separate noncompensable rating for a right knee disability (limitation of flexion), effective September 28, 2021. However, a higher rating is available for both hypertension and a limitation of flexion in the knee. The Veteran is presumed to seek the maximum available benefit for a disability. As such, these claims are still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). 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, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.").] VA amended the criteria for rating musculoskeletal disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. As there is no evidence submitted subsequent to the effective date of the revised diagnostic criteria, the revised diagnostic criteria are not applicable to the instant claim. The Board also notes that the former and revised criteria under Diagnostic Codes 5242, 5260 and 5261 are identical. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to a rating in excess of 20 percent for degenerative disc disease of the lumbar spine is denied. The Veteran maintains that her lumbar spine is more disabling than reflected by the 20 percent rating currently assigned. During her Board hearing, the Veteran testified that she could not sit or stand for long due to her back symptoms and that she often experienced flare-ups of back pain. The Veteran has been assigned a 20 percent rating for her lumbar spine degenerative disc disease under Diagnostic Code 5242. Diagnostic Code 5242 refers the rater to the General Rating Formula for Diseases and Injuries of the Spine, which provides a 20 percent rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, a 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. A 40 percent rating requires evidence of forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is assigned with unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). Alternatively, the Veteran's lumbar spine degenerative disc disease may be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, which assigns a 10 percent rating with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating may be assigned with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating may be assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating may be assigned for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bedrest prescribed by a physician and treatment by a physician. Id. at Note (1). By a rating action in June 2005, the AOJ granted service connection for degenerative disc disease of the lumbar spine, and assigned a 20 percent rating, effective January 6, 2005. In May 2010, the Veteran filed a claim for an increased rating for the lumbar spine disability. In conjunction with her claim, the Veteran was afforded a VA back examination in October 2010, at which time she complained of stiffness, spasms, decreased motion and paresthesia. The Veteran also reported associated weakness of the spine and leg. She did not report having any bowel or bladder problems in relation to her spine condition. The examiner noted that her back pain is exacerbated by physical activity, and she described the pain level as moderate; she noted that the pain is relieved by rest and pain medication. During the flare-ups, she experiences functional impairment which is described as walk slow sometimes with walking stick and limitation of motion of the joint. The examination reveals no evidence of radiating pain on movement. No localized tenderness, guarding or muscle spasms was noted. The examination does not reveal any weakness. Muscle tone is normal. Musculature is normal. Straight leg raising was negative. The Veteran had full range of motion, with 90 degrees of flexion, and 30 degrees of extension, lateral flexion and rotation. The spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. No ankylosis was noted. There are no signs of intervertebral disc syndrome of the lumbar spine. The diagnosis was degenerative disc disease of the lumbar spine. A March 2014 VA examination reflects the Veteran's reports of difficulty bending over; she indicated that she uses a grabber to pick things up. Forward flexion was to 70 degrees, with painful motion starting at 70 degrees. Extension was 30 degrees, with painful motion starting at 30 degrees. Lateral flexion and rotation were all 30 degrees. The Veteran was able to perform repetitive use testing with three repetitions. No change in range of motion after repetitive use testing. Functional impairment was caused by less movement than normal and pain on movement. No localized tenderness, guarding or muscle spasms was noted. Muscle strength testing was normal. No muscle atrophy was noted. Straight leg raising was negative. No radicular pain or other signs or symptoms of radiculopathy was noted. No neurological abnormalities were noted. The Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. It was noted that the Veteran occasionally uses brace and a cane for ambulation. The examiner indicated that the impact of the thoracolumbar spine on the Veteran's ability to work is decreased ability to do prolonged walking and standing. The pertinent diagnosis was degenerative disc disease of the lumbar spine. The Veteran was afforded a February 2021 VA examination. The Veteran reported problems with muscle spasms and stiffness; she stated that she can't stand for too long due to weakness in the legs. The Veteran reported flareups of thoracolumbar spine manifested by more stiffness, especially during cold weather. She stated that walking makes it better, but it's difficult to walk when it's cold outside. She described the severity of her flareups as moderate. Forward flexion was to 70 degrees, extension to 20 degrees, right and left lateral flexion was to 30 degrees, and lateral rotation was to 20 degrees, bilaterally. It was noted that the Veteran had pain with range of motion. There was evidence of pain with weight bearing, non-weight-bearing and active motion. There was no evidence of crepitus or localized tenderness on the lumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions. There was no additional loss of function or range of motion after three repetitions. During flareups, forward flexion was to 60 degrees, extension to 10 degrees, lateral flexion and rotation were all to 20 degrees, bilaterally. It was noted that the Veteran has more stiffness during a flareup which would decrease her range of motion. The examiner indicated that the Veteran does not have localized tenderness, guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing was 5/5. No muscle atrophy was noted. No ankylosis was noted. The Veteran did not have interverbal disc syndrome of the lumbar spine. The Veteran did not have the need of any assistive devices as a normal mode of locomotion. With respect to the impact of the thoracolumbar spine on the Veteran's ability to work, the examiner indicated that the Veteran's would have difficulty with bending, pulling, pushing, and lifting. A March 2021 VA examination reflects the Veteran's reports of radiating pain from back into her legs, worse in left; she also reported having muscle spasms. The Veteran reported flareups of the back with weather changes; she noted that some of the flare-ups are mild and some are severe. She noted that the flare-ups are precipitated by weather changes, standing or sitting for too long. The back flare-ups are alleviated by laying down. Forward flexion was to 60 degrees, extension was to 15 degrees, lateral flexion and rotation were all 20 degrees. The Veteran had pain with forward flexion and extension. The Veteran was able to perform repetitive use testing with three repetitions, without any additional loss of function or range of motion. After repetitive use testing, forward flexion was to 50 degrees, extension to 10 degrees, lateral flexion was to 15 degrees bilaterally, and lateral rotation was to 15 degrees, bilaterally. Functional loss was caused by pain, fatigability and lack of endurance. No ankylosis was noted. The Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. It was noted that the Veteran occasionally uses a cane for ambulation. The pertinent diagnosis was degenerative disc disease of the lumbar spine. The examiner indicated that, due to the Veteran's back condition, she is limited when working jobs that require prolonged standing/walking strenuous physical activity such as pushing, pulling, carrying, lifting, running, and jumping. And, due to the Veteran's radiculopathy, she is limited when working jobs that require exposure to extreme weather conditions or in environmental hazardous areas due to her decreased sensation. The examiner further noted that she is also limited in physically demanding positions as well as sedentary dur to her lack of ability to sit for long periods. A review of the record shows that the Veteran receives treatment at the VA Medical Center for various disabilities. However, there is no indication from the record that her lumbar spine symptoms are manifestly different than those reported at the above-mentioned examinations. Upon review, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran's lumbar spine degenerative disc disease at any point during the appeal period. In that regard, a review of the record does not contain objective evidence that the Veteran experienced forward flexion to 60 degrees, at worst during the appeal period. Significantly, upon VA examination in March 2014, the Veteran's forward flexion was shown to be limited to 70 degrees. In February 2021, the Veteran's forward flexion was shown to be limited to 70 degrees; the examiner indicated that the Veteran was able to perform repetitive use testing with three repetitions. Following repetitive use testing, flexion was to 60 degrees. Here, the VA treatment records and VA examinations do not reveal additional functional impairment, including additional limitation of motion, on account of pain, weakness, etc, that is not already contemplated by the assigned 20 percent rating. 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, supra. Thus, a higher rating is not warranted for the Veteran's lumbar spine degenerative disc disease even in consideration of painful motion and other factors such as weakness, fatigability, lack of endurance, and incoordination. Moreover, there was no ankylosis. Therefore, a rating in excess of 20 percent is not warranted. With regard to disabilities of the spine, VA is to evaluate any associated objective neurologic abnormalities under appropriate diagnostic criteria. See Note (1) of the General Rating Formula. In this regard, while the Veteran has been awarded separate ratings for, in pertinent part, right and left lower extremity radiculopathy, and those ratings are not before the Board. The Board finds that her lumbar spine degenerative disc disease does not result in any additional associated objective neurologic abnormalities, to include bladder or bowel incontinence. In this regard, neurologic abnormalities or findings related to the thoracolumbar degenerative disc disease such as bowel or bladder problems were not found on the various objective examinations of record. Therefore, absent evidence of objective neurologic abnormalities of bladder or bowel incontinence associated with the lumbar spine disorder, the Board finds that separate ratings for such conditions are not warranted. With regard to intervertebral disc syndrome, the evidence must demonstrate incapacitating episodes lasting a total duration of at least four weeks during the past twelve months to warrant an increased rating. In this case, there is no evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. It is noteworthy that during all the above cited VA examinations, it was indicated that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. As such, there is no clinical of record showing the Veteran had incapacitating episodes with bed rest that was prescribed by a physician during the period in question and the Veteran has not made such allegation. Therefore, the Board finds that a higher or separate rating for intervertebral disc syndrome is not warranted. The Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this case, several VA examinations were conducted prior to Correia and Sharp and provides only partial information as described above. The Board notes that the VA examinations did not test the opposite joint; however, the spine does not have an opposite joint. Although the March 2014 VA examination as well as the earlier examinations did not address passive range of motion, the Board notes that active range of motion testing usually results in further limitation than passive range of motion testing. See Massie v. Shinseki, 25 Vet. App. 123, 131 (2011); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Therefore, although the Board notes that the March 2014 VA examination as well as earlier examinations did not complete all the testing required under Correia v. McDonald, supra, the range of motion findings are still the most probative evidence concerning the Veteran's functional limitation at such times. Moreover, VA examiners indicated that range of motion did not contribute to functional loss, and there was no evidence of additional loss of function or range of motion following repetitive-use or during flare-ups. Therefore, the examinations of record are adequate for VA purposes. In reaching its conclusions, the Board acknowledges the Veteran's belief that her lumbar spine degenerative disc disease is more severe than as reflected by the currently assigned ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding her symptomatology, she is not competent to provide an opinion regarding the severity of her symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged her reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than her reports regarding the severity of her lumbar spine degenerative disc disease. The Board has also considered whether a staged rating under Hart v. Mansfield, supra is appropriate for the Veteran's service-connected lumbar spine degenerative disc disease; however, the Board finds that her symptomatology has otherwise been stable throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. Further, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In this case, the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran's lumbar spine degenerative disc disease and the claim must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Entitlement to a rating in excess of 10 percent for right knee patellofemoral syndrome with instability is denied. The Veteran essentially contends that her right knee disorder is more disabling than reflected by the 10 percent rating currently assigned. During her Board hearing, the Veteran testified that her left knee (the nonservice-connected knee) would give out and that she experienced pain and discomfort in the right knee. The Veteran's right patellofemoral pain syndrome is rated by analogy under 38 C.F.R. § 4.71a, Diagnostic Code 5014 for osteomalacia and Diagnostic Code 5257 for instability. She is also in receipt of a separate noncompensable rating for right knee disability (limitation of flexion) under Diagnostic Code 5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Disabilities rated under Diagnostic Code 5014 are rated on limitation of motion of affected parts. Limitation of motion of the knee is rated under Diagnostic Codes 5260 and 5261, for limitation of flexion of the leg and limitation of extension of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion in the knee is zero degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5257 addresses recurrent subluxation or lateral instability of the knee. Under that code, a 30 percent rating is for application where subluxation or lateral instability is severe. A 20 percent rating is for application where subluxation or lateral instability is moderate. A 10 percent rating is for application where subluxation or lateral instability is slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. "Persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. Lastly, regarding patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id., Note (2). By a rating action in June 2005, the AOJ granted service connection for right knee patellofemoral syndrome, and assigned a zero percent rating, effective January 6, 2005. A rating action in September 2006 increased the rating for the right knee from zero percent to 10 percent, effective January 6, 2005. In May 2010, the Veteran filed a claim for an increased rating for the right knee. In conjunction with her claim, the Veteran was afforded a VA examination in October 2010. At that time, the Veteran reported having right knee pain, swelling and lack of endurance. She denied any weakness, stiffness, heat, redness, giving way, locking, fatigability, deformity, tenderness, drainage, effusion, subluxation and dislocation. The Veteran reported having flareups once a day, each time lasting 24 hours; she described the severity of the flareups as an eight. The Veteran indicated that her flare-ups are precipitated by physical activity and occur spontaneously; they are alleviated by ibuprofen. The Veteran indicated that, during the flare-ups, she experiences pain with prolonged standing; she reported difficulty with standing/walking. On examination, the Veteran's posture was described as normal; her gait was normal. The right showed no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment and drainage. There was no subluxation. Examination of the right knee revealed crepitus. There was no genu recurvatum or locking pain. There was no ankylosis. Range of motion was from zero to 140 degrees. On the right, the joint function is not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test and the medial/lateral meniscus stability test are all within normal limits for the right knee. The right knee X-ray results are within normal limits. The pertinent diagnosis was right knee patellofemoral syndrome. The subjective factors are complaints of right knee pain, and the objective factors are tenderness on palpation. A September 2021 VA examination reflects that the Veteran indicated that she experienced popping, pain, and locking in the right knee. The Veteran indicated that she was unable to stand for long periods of time. She stated that the knee pain affects her job because she has to sit too much. She also indicated that the knee gives out on her. Range of motion in the right knee was from zero degrees to 70 degrees. Passive range of motion was the same as active range of motion. There was no evidence of pain. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions, but there was no additional loss of function or range of motion after three repetitions. After repetitive use testing, flexion in the right knee was 65 degrees. No muscle atrophy was noted. No ankylosis was noted. There was recurrent subluxation and persistent instability. The examiner noted occasional use of a brace. The examiner also noted that the Veteran is limited in running, kneeling, crawling, squatting, prolonged standing, prolonged walking and high impact activities due to right knee patellofemoral pain syndrome and right knee instability. The pertinent diagnosis was patellofemoral syndrome, right knee. The examiner noted that the right knee instability was caused by the patellofemoral pain syndrome, which affects the patellofemoral joint. There is slight recurrent subluxation of the right knee. There was a history of slight lateral instability of the right knee. There were no findings of joint instability of the right knee. The right knee anterior instability test result was normal. The right knee posterior instability test result was normal. The right knee medial instability test result was normal. The right knee lateral instability test result was normal. A review of the record shows that the Veteran receives treatment at the VA Medical Center for various disabilities. However, there is no indication from the record that her right knee symptoms are manifestly different than those reported at the above-mentioned examinations. Based on the foregoing, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's right knee patellofemoral pain syndrome. The Veteran denied instability in the May 2010 VA examination and objective examination found the medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test and the medial/lateral meniscus stability test all to be within normal limits. Such would not warrant a higher rating under the former Diagnostic Code 5257. A September 2021 VA examination found slight recurrent subluxation of the right knee without objective evidence of joint instability of the right knee; such would not warrant a higher rating under the revised Diagnostic Code 5257. This version of the regulations is more favorable to the Veteran because a rating higher than 10 percent under the revised version of Diagnostic Code 5257 requires that a brace or assistive device be prescribed for the Veteran and there is no evidence that she has been prescribed any knee brace or assistive device due to her service-connected right knee patellofemoral syndrome. With regards to limitation of motion, the Board notes that right knee range of motion was tested multiple times throughout the appellate period, including during VA examinations in October 2010 and September 2021. The October 2010 VA examination measured flexion at 140 degrees in the right knee, and 65 degrees on repetitive motion during a September 2021 VA examination. Therefore, Board finds that such factors do not result in functional loss more nearly approximating flexion limited to 45 degrees or extension limited to 10 degrees in the right knee. See DeLuca v. Brown, supra; Mitchell v. Shinseki, supra. Therefore, such range of motion findings, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination or as a result of repetitive motion and/or flare-ups, do not meet the requirements for a higher or separate rating under Diagnostic Code 5260 or 5261. There is also no evidence of impairment of the tibia and fibula, genu recurvatum, or dislocation of the semilunar cartilage of the right knee to warrant a separate rating under Diagnostic Codes 5258, 5262, and 5263. Diagnostic studies have not shown these abnormalities, and they have not been reported elsewhere in the record. Moreover, as the Veteran has retained motion in her right knee throughout the period on appeal, by definition she does not have ankylosis. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). Therefore, Diagnostic Codes 5256, 5262, and 5263 are not for application in this case. Here, the Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, supra and Sharp v. Shulkin, supra. In this case, the October 2010 VA examination was conducted prior to Correia and Sharp and provides only partial information as described above. Both the October 2010 and September 2021 VA examinations reflected range of motion measurements for both knees. The September 2021 VA examination measured active and passive range of motion and range of motion on repetitive use testing as well as range of motion on weight-bearing and non-weight-bearing; the effect of pain on range of motion is described above. With regards to flare-ups, the Veteran reported flare-ups of pain and difficulty standing and walking in the October 2010 VA examination. She denied flare-ups in the September 2021 VA examination. Her reports of additional functional loss associated with the flare-ups as described above. Sharp v. Shulkin, supra. Therefore, VA examinations are adequate for adjudication purposes. In reaching its conclusions, the Board acknowledges the Veteran's belief that her right knee patellofemoral syndrome is more severe than as reflected by the currently assigned rating. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding her symptomatology, she is not competent to provide an opinion regarding the severity of her symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged her reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than her reports regarding the severity of her right knee patellofemoral syndrome. The Board has also considered whether staged rating under Fenderson v. West, supra is appropriate for the Veteran's service-connected right knee patellofemoral syndrome; however, the Board finds that her symptomatology has otherwise been stable throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. Further, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, supra. In this case, the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's right knee patellofemoral syndrome and the claim must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Entitlement to a rating in excess of 10 percent for seasonal allergic rhinitis is denied. The Veteran contends that she is entitled to a higher rating for her allergic rhinitis. During her Board hearing, the Veteran testified that she used medication to treat her rhinitis and that she experienced symptoms once or twice a week. Allergic rhinitis is rated under Diagnostic Code 6522. 38 C.F.R. § 4.97. Under that code, a 10 percent evaluation is warranted for allergic rhinitis without polyps, but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6522. A 30 percent rating is warranted for allergic rhinitis with polyps. Id. The Veteran underwent a VA examination in October 2010 in conjunction with this claim. At that time, the Veteran reported sinus problems that occur four times per year with each episode lasting three weeks. During each episode, she is incapacitated as often as two times per year and lasting for three days. She experiences headaches with her sinus episodes. No antibiotic treatment lasting three to six weeks is needed for her sinus problem. She reported interference with breathing through the nose, hoarseness of the voice, pain and blood clots in nose. She had no purulent discharge from the nose and crusting. The bone condition has never been infected. She reported taking Antibiotics for sinus. The claimant reports that she does not experience any overall functional impairment from this condition. Examination of the nose revealed nasal obstruction and the percentage of obstruction in the right nostril is 10 percent and also 10 percent in the left nostril. Nose examination did not reveal deviated septum, loss of part of the nose, loss of part of the ala, a scar, obvious disfigurement, or nasal polyps. The examiner noted the presence of rhinitis and stated that it is believed to be allergic in origin because of nasal congestive and itchiness. No sinusitis was detected. A September 2021 VA examination report reflects the Veteran's reports of sinus pressure, drainage, sneezing, and nasal irritation. The Veteran indicated that, when she gets sick enough, she has to miss work. The examiner indicated that there was greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. She did not have complete obstruction of the right or left side due to rhinitis. She had permanent hypertrophy of the nasal turbinates. There were no nasal polyps. She had not lost part of the nose or other scars of the nose exposing both nasal passages. X-ray study of the sinus was normal. The examiner indicated that the Veteran's rhinitis would cause decreased productivity and efficiency related to breathlessness, easy fatigue with low endurance during all physical activity which require her to take rest breaks to recover due to the allergic rhinitis. After reviewing the evidence of record, the Board finds that a rating in excess of 10 percent for allergic rhinitis is not warranted. In order to warrant a 30 percent rating the Veteran's allergic rhinitis would need to include polyps. VA examinations dated October 2010 and September 2021 both report that the Veteran does not have nasal polyps. In the absence of evidence of nasal polyps, the findings do not more nearly approximate or equate to the criteria for a 30 percent rating under Diagnostic Code 6522. In reaching its conclusions, the Board acknowledges the Veteran's belief that her allergic rhinitis is more severe than as reflected by the currently assigned rating. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding her symptomatology, she is not competent to provide an opinion regarding the severity of her symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged her reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than her reports regarding the severity of her allergic rhinitis. The Board has also considered whether staged rating under Fenderson v. West, supra is appropriate for the Veteran's service-connected allergic rhinitis; however, the Board finds that her symptomatology has otherwise been stable throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. Further, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, supra. In this case, the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's allergic rhinitis and the claim must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 4. Entitlement to an increased rating for hypertension, rated as noncompensably disabling prior to September 28, 2021, and 10 percent disabling thereafter, is denied. The Veteran contends that a higher rating is warranted for her hypertension. During her Board hearing, the Veteran testified that she had been using three medications to treat her hypertension. During the period on appeal, the Veteran's hypertension is rated under the 38 C.F.R. § 4.71a, Diagnostic Code 7101. Under Diagnostic Code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, systolic pressure predominantly 160 or more, or for a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure that is predominantly 120 or more; and the highest rating of 60 percent rating is assigned where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Board notes that the use of medications is explicitly contemplated in Diagnostic Code 7101 and that the Court has held that the Board did not err in failing to discount the ameliorative effects of blood pressure medication as the plain language of Diagnostic Code 7101 contemplates the effects of medications. McCarroll v. McDonald, 28 Vet. App. 267, 272-73 (2016). The Board also emphasizes that more than one blood pressure reading is not required for evaluation purposes for rating hypertension under VA regulations. See Gill v. Shinseki, 26 Vet. App. 386, 391 (2013) (holding that the need for a specific number of blood pressure readings over multiple days is not required for determining disability evaluation, as the need for multiple blood pressure readings pertains only to the confirmation of the existence of hypertension). The Board finds that a compensable rating is not warranted for the appeal period prior to September 28, 2021. An October 2010 VA examination report indicates that the Veteran used atenolol daily, that there were no side effects and that her blood pressure readings were 136/90 in November 2013, 117/84 in December 2013, 137/96, 156/98 and 132/94. Clinical records reflect that the Veteran's blood pressure was found to be 120/85 in April 2015, 127/76 in November 2017, 132/82 in November 2017, 128/90 in April 2019, 131/96 in April 2019 and 134/82 in March 2020. Such does not reflect diastolic pressure predominantly 100 or more, systolic pressure predominantly 160 or more, or for a history of diastolic pressure predominantly 100 or more. Therefore, a compensable rating is not warranted prior to September 28, 2021. For the appeal period beginning on September 28, 2021, the Board finds that a rating in excess of 10 percent for hypertension is not warranted for the appeal period. A September 2021 VA examination noted that the Veteran used medication to control her hypertension and that her blood pressure readings were 165/104, 150/109, 171/111. While the Veteran's hypertension requires continuous medication, there is no indication that her hypertension is, or has historically been, predominantly manifested by diastolic pressure that is 110 or more. Instead, the evidence shows diastolic pressures to be consistently less than 110 and systolic pressures to be consistently less than 200. These readings are not supportive of a higher 20 percent rating under Diagnostic Code 7101. The Board notes that words such as "predominantly" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Regardless, a basic understanding of predominant would suggest that blood pressure readings were above a certain level more often than below it. Here, they clearly were not. The Board finds that a higher rating is not warranted at any time during the appeal period. In reaching its conclusions, the Board acknowledges the Veteran's belief that her hypertension is more severe than as reflected by the currently assigned rating. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding her symptomatology, she is not competent to provide an opinion regarding the severity of her symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged her reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than her reports regarding the severity of her hypertension. The Board has also considered whether staged rating under Fenderson v. West, supra is appropriate for the Veteran's service-connected hypertension; however, the Board finds that her symptomatology has otherwise been stable throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. Further, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, supra. In this case, the preponderance of the evidence is against a compensable rating prior to September 28, 2021 and a rating in excess of 10 percent thereafter for the Veteran's hypertension and the claim must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 4. Entitlement to a TDIU by reason of service-connected disabilities is granted as of May 29, 2020. The Veteran contends that she is unemployable as a result of the combined effects of her service-connected disabilities. In a January 2021 Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran reported that she had a college degree and had work experience as an investigator. The Veteran indicated that she last worked on May 29, 2020. The Veteran also indicated that she briefly worked in adult education but was discharged in August 2020 for the failure to perform the essential duties of the job; there is no indication that this employment in adult education was gainful. Total disability ratings for compensation may be assigned, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering a veteran's master's degree in education and his part-time work as a tutor). The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). In order to establish entitlement to TDIU benefits, there must be impairment so severe that a claimant cannot follow a substantially gainful occupation. 38 C.F.R. § 3.340. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The issue is whether the Veteran's service-connected disabilities preclude her from engaging in substantially gainful employment (i.e., work that is more than marginal, that permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training and previous work experience, but not to her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In this case, the Veteran is service connected for depressive disorder due to chronic pain from degenerative disc disease of the lumbar spine and degenerative arthritis of the cervical spine, rated as 50 percent disabling; degenerative disc disease of the lumbar spine, rated as 20 percent disabling; postoperative degenerative arthritis, cervical spine, associated with degenerative disc disease of the lumbar spine, rated as 20 percent disabling; cervical radiculopathy, right upper extremity, rated as 20 percent disabling; patellofemoral syndrome of the right knee, rated as 10 percent disabling; seasonal allergic rhinitis, rated as 10 percent disabling; recurrent bilateral tinnitus, rated as 10 percent disabling; radiculopathy, right lower extremity, rated as 10 percent disabling; radiculopathy, left lower extremity, rated as 10 percent disabling; and right ankle tendonitis, hypertension, bilateral hearing loss, and surgical scar of the neck, associated with postoperative degenerative arthritis, each rated as zero percent disabling. The Veteran's combined rating is 80 percent from April 15, 2014, and 90 percent from January 7, 2021. Therefore, the schedular criteria for an award of TDIU is met. Having determined that the Veteran meets the percentage threshold requirements, the remaining inquiry is whether she is unable to secure or follow substantially gainful occupation as a result of such service-connected disabilities. For reasons stated below, the Board finds that the evidence of record demonstrates that the Veteran's service-connected disabilities render her unable to secure and follow a substantially gainful occupation. Considering all evidence of record, the Board finds that the evidence is at least in relative equipoise on the question of whether the Veteran is unable to work as a result of the combined effects of her service-connected disabilities. Significantly, following a VA examination in March 2014, the examiner stated that the impact of the thoracolumbar spine on the Veteran's ability to work is decreased ability to do prolonged walking and standing. In February 2021, a VA examiner indicated that the Veteran's lumbar spine degenerative disc disease would cause difficulty with bending, pulling, pushing, and lifting. In addition, following an examination of the back in March 2021, the VA examiner stated that, due to the Veteran's back condition, she is limited when working jobs that require prolonged standing/walking strenuous physical activity such as pushing, pulling, carrying, lifting, running, and jumping. The March 2021 VA examiner also stated that due to the Veteran's radiculopathy, she is limited when working jobs that require exposure to extreme weather conditions or in environmental hazardous areas due to her decreased sensation. The March 2021 VA examiner further noted that she is also limited in physically demanding positions as well as sedentary due to her lack of ability to sit for long periods. In a March 2021 opinion, a VA psychologist noted that the Veteran has difficulty functioning around other people, has difficulty functioning as a team member, and feels uncomfortable around others, but there does not appear to be any mental health impediments to sedentary work. Moreover, following a VA examination of the sinuses in September 2021, the examiner stated that the Veteran's rhinitis would cause decreased productivity and efficiency related to breathlessness, easy fatigue with low endurance during all physical activity which require her to take rest breaks to recover due to the allergic rhinitis. The Board has carefully considered the Veteran's statements, and the medical evidence of record, regarding the combined effects of her depressive disorder, lumbar spine degenerative disc disease and cervical spine degenerative arthritis as it impacts his employment. The Board concludes that the Veteran experienced significant limitation as a result of the combination of her service-connected depressive disorder, lumbar spine degenerative disc disease and cervical spine degenerative arthritis, and that the combined effect of these disabilities impacted her daily functioning and earning capacity that rendered the Veteran unable to secure or follow a substantially gainful occupation as of May 29, 2020. Generally, the fact that she was having impairments or difficulties does not provide a basis to grant TDIU. However, based on the evidence as discussed above, the Board notes the combined effects of her psychiatric limitations and the physical impairments as a result of his physical symptoms, to include a decreased ability to do prolonged walking and standing and difficulty with bending, pulling, pushing, and lifting. In addition, the Veteran has difficulty functioning around other people, has difficulty functioning as a team member, and feels uncomfortable around others. (Continued on the next page) Therefore, based on the foregoing, the Board finds that the combined effects of the Veteran's service-connected disabilities rendered her unable to secure and follow a substantially gainful occupation and entitlement to a TDIU as of May 29, 2020 is warranted. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Suzie S. Gaston, 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.