Citation Nr: 21075816 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 14-17 937 DATE: December 21, 2021 ORDER A disability rating of 60 percent, and no higher, for right knee arthritis with limited range of motion, status post total right knee replacement, is granted effective August 30, 2019. A disability rating greater than 30 percent prior to August 30, 2019 for right knee arthritis with limited range of motion, status post total right knee replacement is denied. A disability rating greater than 20 percent for diabetes mellitus is denied. A disability rating greater than 10 percent prior to November 12, 2019 and greater than 30 percent thereafter for right upper extremity neuropathy is denied. A disability rating greater than 10 percent prior to November 12, 2019 and greater than 30 percent thereafter for left upper extremity neuropathy (minor extremity) is denied. A disability rating of 40 percent, and no higher, for right lower extremity neuropathy is granted effective August 30, 2019. A disability rating greater than 20 percent prior to August 30, 2019 for right lower extremity neuropathy is denied. A disability rating of 40 percent, and no higher, for left lower extremity neuropathy is granted effective August 30, 2019. A disability rating greater than 20 percent prior to August 30, 2019 for left lower extremity neuropathy is denied. An initial disability rating of 70 percent prior to November 4, 2019 for posttraumatic stress disorder (PTSD) with secondary depression, is granted. A disability rating greater than 70 percent since November 4, 2019 for PTSD with secondary depressions is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. FINDINGS OF FACT 1. Prior to August 30, 2019, the Veteran's right knee disability was manifested by, at worst, flexion to 0 degrees and extension to 120 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups. There was no demonstration of ankylosis, lateral instability or recurrent subluxation, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. Furthermore, there was no evidence of chronic residuals consisting of severe painful motion or weakness in the right knee. 2. From August 30, 2019 to the time of his death, the Veteran's right knee disability was manifested by chronic residuals consisting of severe painful motion or weakness in the right knee. 3. Pertinent to the period on appeal prior to his death, the Veteran's diabetes mellitus was manifested with the need for restricted diet, insulin and oral hypoglycemic agents, but without the need to avoid strenuous occupational and recreational activities. 4. Prior to November 12, 2019, the Veteran's right upper extremity neuropathy was manifested by no more than mild incomplete paralysis of the median nerve. 5. Beginning November 12, 2019 to the time of his death, the Veteran's right upper extremity neuropathy was manifested by no more than moderate incomplete paralysis of the median nerve. 6. Prior to November 12, 2019, the Veteran's left upper extremity neuropathy was manifested by no more than mild incomplete paralysis of the median nerve. 7. Beginning November 12, 2019 to the time of his death, the Veteran's left upper extremity neuropathy (minor extremity) was manifested by no more than moderate incomplete paralysis of the median nerve. 8. Prior to August 30, 2019, the Veteran's right lower extremity neuropathy was manifested by no more than moderate incomplete paralysis of the sciatic nerve. 9. Beginning August 30, 2019 to the time of his death, the Veteran's right lower extremity neuropathy was manifested by no more than moderately severe incomplete paralysis of the sciatic nerve. 10. Prior to August 30, 2019, the Veteran's left lower extremity neuropathy was manifested by no more than moderate incomplete paralysis of the sciatic nerve. 11. Beginning August 30, 2019 to the time of his death, the Veteran's left lower extremity neuropathy was manifested by no more than moderately severe incomplete paralysis of the sciatic nerve. 12. Since the grant ot service connection to the time of his death, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in areas such as work, thinking and mood due to such symptoms as: depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty adapting to stressful circumstances, including work or a work like setting. There were not more severe manifestations that more nearly approximated total occupational and social impairment. 13. Resolving all reasonable doubt in the Veteran's favor, prior to his death he was unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities. CONCLUSIONS OF LAW 1. Beginning August 30, 2019, and no earlier, to the time of his death, the criteria for a disability rating of 60 percent, and no higher, for the Veteran's right knee disability were met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5055. 2. Prior to August 30, 2019, the criteria for a disability rating greater than 30 percent for the Veteran's right knee disability were not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5055. 3. Prior to his death, the criteria for a disability rating greater than 20 percent for diabetes mellitus were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.7, 4.20, 4.119, DC 7913. 4. Prior to November 12, 2019, the criteria for a disability rating greater than 10 percent for right upper extremity neuropathy were not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8615. 5. Beginning November 12, 2019 to the time of his death, the criteria for a disability rating greater than 30 percent for right upper extremity neuropathy were not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8615. 6. Prior to November 12, 2019, the criteria for a disability rating greater than 10 percent for left upper extremity neuropathy were not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8615. 7. Beginning November 12, 2019 to the time of his death, the criteria for a disability rating greater than 20 percent for left upper extremity neuropathy were not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8615. 8. Beginning August 30, 2019, and no earlier, to the time of his death, the criteria for a disability rating of 40 percent, and no higher, for the Veteran's right lower extremity neuropathy were met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8520. 9. Prior to August 30, 2019, the criteria for a disability rating greater than 20 percent for right lower extremity neuropathy were not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8520. 10. Beginning August 30, 2019, and no earlier, to the time of his death, the criteria for a disability rating of 40 percent, and no higher, for the Veteran's left lower extremity neuropathy were met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8520. 11. Prior to August 30, 2019, the criteria for a disability rating greater than 20 percent for left lower extremity neuropathy were not met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.124a, DC 8520. 12. Since the grant of service connection to the time of his death, the criteria for a 70 percent disability rating, but no higher, for PTSD were met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code (DC) 9432. 13. Prior to his death, the criteria for a TDIU were met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1961 to September 1969. He died in January 2020. The appellant is the Veteran's widow. These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, continued a 30 percent disability rating for the Veteran's right knee disability; continued a 20 percent disability rating for the Veteran's diabetes; continued separate 10 percent disability ratings for the Veteran's bilateral upper extremity neuropathy; increased the Veteran's disability ratings for bilateral lower extremity neuropathy from 10 to 20 percent disabling effective September 28, 2010, and granted service connection for PTSD, assigning a 30 percent disability rating effective September 28, 2010. The Veteran disagreed with this decision and perfected this appeal. Subsequently, by rating decision dated in March 2014, the RO granted a temporary total rating for the Veteran's right knee disability from April 1, 2003 to May 1, 2003 (pursuant to 38 C.F.R. § 4.30 based on surgical treatment necessitating convalescence following knee surgery); assigned even earlier effective dates of July 2, 2010 for the 20 percent ratings assigned for the bilateral lower extremity radiculopathy; and assigned a separate noncompensable rating for a scar of the Veteran's right knee effective June 6, 2003. This case was previously before the Board in April 2018 at which time the Board took jurisdiction of the TDIU issue pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009) based on the Veteran's allegations that he is unemployable due to service-connected disabilities and remanded the matters for additional development. As above, the Veteran died in January 2020. Thereafter, the Veteran's widow requested to be substituted as the appellant for purposes of processing claims on appeal at the time of the Veteran's death. See 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010; see also 79 Fed. Reg. 52977-85 (Sept. 5, 2014). This request for substitution was granted in October 2020. Thereafter, by rating decision dated in March 2021, the RO, in part, increased the disability rating for the Veteran's right knee disability from 30 to 60 percent disabling beginning November 12, 2019; increased the disability rating for the Veteran's PTSD with depression from 30 to 70 percent disabling beginning November 4, 2019; increased the disability rating for the Veteran's right knee disability from 30 to 60 percent disabling beginning November 12, 2019; increased each of the separate disability ratings for the Veteran's bilateral lower extremity neuropathy from 20 to 40 percent disabling beginning November 12, 2019; increased the disability rating for the Veteran's right upper extremity neuropathy from 10 to 30 percent disabling beginning November 12, 2019; increased the disability rating for the Veteran's left upper extremity neuropathy from 10 to 20 percent disabling beginning November 12, 2019; continued a 20 percent disability rating for the Veteran's diabetes; assigned a separate 20 percent disability rating for diabetic cataracts effective November 6, 2019; and continued a noncompensable disability rating for the Veteran's right knee scar. Then, by rating decision dated in June 2021, the RO denied a TDIU. The case was again before the Board in August 2021 at which time it was, once again, remanded for additional development. General Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 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 picture more nearly approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. A disability rating of 60 percent, and no higher, for right knee arthritis with limited range of motion, status post total right knee replacement, is granted effective August 30, 2019; a disability rating greater than 30 percent prior to August 30, 2019 is denied. The Veteran's widow seeks higher disability ratings for the Veteran's service-connected right knee disability prior to his death. By way of history, the Veteran's service treatment records show that he injured his right knee playing football in September 1965 and underwent two surgeries in service in an attempt to repair the damage. He submitted an initial claim for service connection for a right knee disability in October 1969 and, by rating decision dated in February 1970, the RO granted service connection for instability of the right knee with traumatic arthritis, assigning a 30 percent disability rating effective October 1, 1969 pursuant to 38 C.F.R. § 4.71a, DC 5257. Subsequently, by rating decision dated in July 1976, the RO decreased the disability rating for the right knee from 30 to 20 percent disabling effective April 2, 1976. This 20 percent disability rating was continued in December 1984 and April 1994 rating decisions (with a temporary total rating from October 20, 1992 to November 30, 1991 pursuant to 38 C.F.R. § 4.30 based on surgical treatment necessitating convalescence following knee surgery). Then, in a June 2003 rating decision, the RO increased the Veteran's disability rating for the right knee from 20 to 30 percent disabling effective September 30, 2002, switching the Veteran's diagnostic code for this disability from DC 5257 (pertaining to instability) tor DC 5055 (pertaining to total knee replacement), and also assigned a temporary total rating from March 21, 2003 to April 1, 2004 pursuant to 38 C.F.R. § 4.30. The 30 percent disability rating for the right knee was then continued in July 2004 and June 2009 rating decisions. The Veteran submitted the current claim on appeal for an increased rating for a right knee disability on September 28, 2010. As above, by rating decision dated in May 2011, the RO continued a 30 percent disability rating for the Veteran's right knee disability and the Veteran perfected an appeal as to this decision. Subsequently, by rating decision dated in March 2014, the RO granted a temporary total rating for the Veteran's right knee disability from April 1, 2003 to May 1, 2003 pursuant to 38 C.F.R. § 4.30. Most recently, by rating decision dated in March 2021, the RO, in part, increased the disability rating for the Veteran's right knee disability from 30 to 60 percent disabling beginning November 12, 2019. Legal Criteria As above, the Veteran's right knee disability was originally rated under 38 C.F.R. § 4.71a, DC 5257. However, since 2003, when the Veteran had his right knee replaced, the disability rating (and diagnostic code) changed, because his disability changed. It is now characterized as total knee replacement, and is rated pursuant to 38 C.F.R. § 4.71a, DC 5055. Under DC 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to DCs 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a. Under DC 5256, a 30 percent rating is warranted for ankylosis of the knee with favorable angle in full extension or slight flexion between 0 degrees and 10 degrees. Under DC 5262, a malunion of the tibia and fibula of either lower extremity warrants a 20 percent evaluation if there is a marked knee or ankle disability. Normal flexion of the knee is to 140 degrees. 38 C.F.R. § 4.71, Plate II. Pursuant to DC 5260, a noncompensable rating is warranted when there is limitation of flexion of a leg to 60 degrees. A 10 percent disability rating is warranted if flexion is limited to 45 degrees. A 20 percent disability rating is warranted if flexion is limited to 30 degrees. A 30 percent disability rating is warranted if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Normal extension of the knee is to 0 degrees. 38 C.F.R. § 4.71, Plate II. Pursuant to DC 5261, a noncompensable rating is warranted when there is limitation of extension of a leg to 5 degrees. A 10 percent disability rating is warranted if extension is limited to 10 degrees. A 20 percent disability rating is warranted if extension is limited to 15 degrees. A 30 percent disability rating is warranted if extension is limited to 20 degrees. A 40 percent disability rating is warranted if extension is limited to 30 degrees. A 50 percent disability rating is warranted if extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Pursuant to DC 5262, impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability, and a 20 percent disability rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace Effective February 7, 2021, several changes to the diagnostic codes used for rating musculoskeletal disabilities were made. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). When a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant generally applies. Only the former criteria can be applied for the period prior to the effective date of the new criteria. However, both the old and new criteria can be applied as of that date. See VAOPGCPREC 7-2003 (Nov. 19, 2003); see also 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114. While the appellant has not yet been notified of all applicable regulatory changes and considered this claim under such regulations, the Board notes that the Veteran died in January 2020, prior to the change in rating criteria beginning February 7, 2021. As such, the new criteria will not be considered at this time. Also pertinent to this claim are 38 C.F.R. §§ 4.40 and 4.45. 38 C.F.R. § 4.40 notes that disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. 38 C.F.R. § 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly). 38 C.F.R. § 4.45. The United States Court of Appeals for Veterans Claims (Court) has held that when a diagnostic code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Also, the Court has held that "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). 38 C.F.R. § 4.59 states 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." As such, pursuant to Correia, an adequate VA joints examination must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and nonweight-bearing conditions. Relevant Evidence Evidence relevant to the current level of severity of the Veteran's right knee disability prior to his death includes VA knee examinations dated in November 2010 and November 2019. During the November 2010 VA knee examination, the Veteran reported that he first injured his right knee in 1965 and underwent surgeries in 1966, 1968, 1992, and 2003 (right knee replacement). He denied right knee pain, but stated that he limps with a leg length difference since his right knee replacement. The Veteran described weakness to the right leg. He denied redness or heat at the right knee but did complain of occasional right knee swelling. He denied right knee instability. He was able to walk approximately one block but then needed to stop to rest, not secondary to knee pain, but secondary to back or groin pain. He had infrequent flares of the right knee with swelling occurring approximately two times per week. He avoided climbing stairs, which increases his right knee symptoms and pain. Symptoms usually resolved with getting off his knee and use of pain medication, which he takes once each day. He wore no knee brace or support and did not use an assistive device for walking. It was noted that the Veteran previously worked as an administrator of a nonprofit organization and in private schools run by his wife until 2007 when he stopped working secondary to his back disability. He was limited in climbing stairs, kneeling, and prolonged walking secondary to knee complaints. On physical examination, the Veteran walked a mild limp. The right knee was nontender and nonpainful to palpation. There was no redness, heat, or swelling. The knee was stable to varus-valgus stress and anterior drawer testing was negative. Range of motion testing of the right knee revealed 120 degrees of flexion (out of 140 degrees) and 0 degrees of extension (normal). On three repetitions of range of motion of the right knee, there was no decrease in range of motion secondary to pain, fatigue, weakness, or lack of endurance. Strength testing of the quadriceps and hamstrings was 5/5, or normal, bilaterally. The diagnosis was right knee arthritis with limited range of motion status post total knee replacement, stable. During the November 2019 VA knee examination, the examiner reviewed the claims file and continued diagnoses of right knee joint osteoarthritis and total knee replacement but also noted prior diagnoses of meniscal tear (1967) as well as anterior cruciate ligament tear (1969). At that time, the Veteran reported that his right knee condition had progressed since his in-service injury and that he was experiencing both pain and decreased motion in the right knee which he treated with physical therapy. The Veteran reported experiencing flare-ups of the knees, described as increased pain and decreased range of motion. The Veteran also reported functional loss/impairment off the knees, described as an inability to walk. Range of motion testing of the right knee revealed flexion to 100 degrees and extension to 0 degrees. This contributed to a functional loss, described as an inability to stand on his own. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue but there was evidence of pain with weight bearing as well as objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of function or range of motion. The Veteran's knees were not examined immediately after repetitive use over time and the examiner found that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain significantly limited functional ability with repeated use over a period of time, specifically flexion to 90 degrees and extension to 0 degrees for the right knee. Similarly, the Veteran's knees were not examined during a flare-up and the examiner found that the examination was medically consistent with the Veteran's statements describing functional loss during flare-ups. Pain significantly limited functional ability with flare-ups, specifically flexion to 70 degrees and extension to 0 degrees for the right knee. There were no additional factors contributing to disability of the right knee. Muscle strength testing was slight abnormal for the right knee, described as "active movement against some resistance." There was also a reduction in muscle strength due to the diagnosed right knee disabilities. There was no muscle atrophy and no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. There was no history of recurrent subluxation, lateral instability, and/or effusion and joint stability testing was normal. There was no evidence of recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There was a history of a meniscal condition., specifically meniscal tear for which the Veteran underwent surgery. It was noted that the Veteran underwent right knee joint replacement in 2003 resulting in chronic residuals consisting of severe painful motion or weakness. It was also noted that the Veteran underwent meniscectomy in 1967 resulting in increased pain and decreased range of motion. There were no other pertinent findings other than scars which were neither painful, unstable, nor had a total area equal to or greater than 39 square centimeters. The Veteran did use an assistive device to aid with locomotion, specifically a wheelchair. The examiner noted that the Veteran's knee disorders did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing revealed degenerative or traumatic arthritis. The examiner found that the Veteran's right knee disability impacted his ability to perform occupational tasks, specifically the Veteran was unable to stand or walk and unable to engage in prolonged sitting. With regard to Correia, the examiner noted that there was no objective evidence of pain on non-weight bearing. The examiner further noted that the range of motion findings above pertained to both active and passive movement. Also of record are VA treatment records dated through the Veteran's death in January 2020. Significantly, these records show that the Veteran began using a wheelchair sometime between December 2018 and August 2019. Significantly, April 2011 and December 2018 VA treatment records show that the Veteran does not regularly use a wheelchair but an August 2019 VA treatment record shows that the Veteran was restricted to a wheelchair and a September 2019 VA treatment record shows that the Veteran was recently restricted to a wheelchair due to recent lower extremity weakness. Analysis Upon review of the evidence, the Board finds that a disability rating of 60 percent is warranted for the right knee beginning August 30, 2019. As above, an August 30, 2019 VA treatment record shows that the Veteran was restricted to a wheelchair and a September 2019 VA treatment record shows that the Veteran was recently restricted to a wheelchair due to recent lower extremity weakness. Such is evidence of chronic residuals consisting of severe painful motion or weakness in the affected extremity warranting a 60 percent disability rating under DC 5055. Regarding the period of time prior to August 30, 2019, the Board finds that a disability rating greater than 30 percent is not warranted. Significantly, prior to August 30, 2019 there was no evidence of chronic residuals consisting of severe painful motion or weakness in the affected extremity warranting a 60 percent disability rating under DC 5055. As above, during the November 2010 VA examination, the Veteran denied experiencing right knee pain and was found to have right knee flexion to 120 degrees and extension to 0 degrees. With regard to the potential for a higher rating based on additional loss of motion due to flare-ups of the right knee pursuant to Sharp, while the Veteran reported experiencing flare-ups during the November 2019 VA examination and the examiner found that, such flare-ups, limit the Veteran's flexion to 70 degrees, the Board notes that such loss of flexion does not support a higher rating as, a 30 percent disability rating is the highest rating possible under DC 5260 and actually contemplates flexion which is far more limited (to 15 degrees). With regard to the possibility of a separate compensable disability rating for the right knee, there is no evidence of ankylosis, loss of extension, or impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5261, and 5262, are not for application. As for the potential for an even higher rating beginning August 30, 2019, the Veteran has only had his right knee replaced once. As such, a 100 percent rating under DC 5055 is not warranted. There are no other applicable diagnostic codes that would afford him a schedular rating in excess of 60 percent. Notably, DCs 5256, 5261, and 5262 do not provide for ratings higher than 50 percent. Significantly, the Veteran's chronic residuals consisting of severe painful motion and weakness are contemplated by the 60 percent assigned beginning August 30, 2019. The Board accepts that the Veteran has functional impairment, pain, and pain on motion (see DeLuca) and finds the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for higher ratings. The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned ratings are warranted and no more. As the preponderance of the evidence is against higher disability ratings for the right knee at any time during the appeal period, the claims are denied. 2. A disability rating greater than 20 percent for diabetes mellitus is denied. The Veteran's widow seeks a higher disability rating for the Veteran's service-connected diabetes mellitus prior to his death. By way of history, the Veteran submitted an initial claim for service connection for diabetes in December 2002 and, by rating decision dated in June 2003, the RO granted service connection for diabetes with cataracts, assigning a 20 percent disability rating effective December 1, 2001 based on his presumed exposure to herbicides during his active service in Vietnam. This 20 percent rating was continued in a June 2009 rating decision. The Veteran submitted the current claim for an increased rating for his diabetes mellitus in September 2010 and, by rating decision dated in May 2011, the RO continued a 20 percent disability rating. The Veteran disagreed with this decision and perfected this appeal. Notably, as above, in a March 2021 rating decision, the RO assigned a separate 20 percent disability rating for diabetic cataracts effective November 6, 2019. Furthermore, as noted in more detail below, the Veteran was in receipt of separate ratings for his service-connected diabetic neuropathy of the bilateral upper and lower extremities. The Veteran's service-connected diabetes mellitus is currently rated as 20 percent disabling under DC 7913. Pursuant to DC 7913, a rating of 20 percent is assigned for diabetes mellitus requiring insulin and a restricted diet or an oral hypoglycemic agent and a restricted diet. A higher 40 percent rating requires insulin, a restricted diet, and regulation of activities. An even higher rating of 60 percent if there is a requirement of insulin, restricted diet, and regulation of activities and episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or visits to a diabetic care provider twice a month plus complications that would not be compensable if separately evaluated. The highest possible rating of 100 percent is assigned when there is the requirement of more than one daily injection of insulin, a restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) and episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. Note 1 to DC 7913 indicates that noncompensable complications are considered part of the diabetic process. Evidence relevant to the current level of severity of the Veteran's diabetes includes November 2010 and November 2019 VA examinations. During the November 2010 VA examination, the Veteran reported that he was diagnosed with diabetes in 1998 and received regular care for this disability through VA. His symptoms included dizziness and sweating when blood glucose levels are low. This occurred approximately three times per week. He checked his blood glucose levels daily and noted that, if he takes his medication, his level usually ran around 140. He did forget his medication occasionally. He denied any hospitalizations for his diabetes and also denied ketoacidosis. His weight was stable over the last year and he tried to follow a low calorie/low carbohydrate diet. Medications included Glyburide (10 mg) as well as Metformin (1000 mg), each twice daily. The Veteran had a history of bilateral adrenal hyperplasia which was stable. There were no symptoms of functional bowel or bladder disorders. He voided 4 to 5 times per day and 2 times per night. He had had a vasectomy 30 years earlier. He used Levitra as needed for sexual function. Significantly, the examiner noted that the Veteran had no restrictions in activities of daily living secondary to diabetes. He retired from his previous job as an administrator for a nonprofit organization in 2007 due to a back disability. During the November 2019 VA diabetes examination, the examiner continued a diagnosis of diabetes. It was noted that the Veteran treated his diabetes with prescribed oral hypoglycemic agents but that the Veteran did not require regulation of activities as part of medical management for his diabetes. It was noted that the Veteran visited his diabetic care provider less than two times per month and that there had been no treatment and/or hospitalizations for either ketoacidosis or hypoglycemia in the last 12 months. There was no progressive unintentional weight loss or loss of strength attributable to diabetes. There were, however, complications of the Veteran's diabetes, specifically diabetic peripheral neuropathy, diabetic retinopathy, as well as erectile dysfunction (which are each rated separately). There were no other pertinent physical findings, complications, signs, or symptoms related to the Veteran's diabetes, to include scars. Diagnostic testing revealed a fasting plasma glucose test (FPG) of >=126 mg/dl on two or more occasions as well as an A1C of 6.5% or greater on 2 or more occasions. With regard to functional impact, it was noted that the Veteran's diabetes did not impact his ability to work. Also of record are VA treatment records dated through the Veteran's death in January 2020. These records are consistent with the findings of the November 2010 and November 2019 VA examination reports. As above, April 2011 and December 2018 VA treatment records show that the Veteran does not regularly use a wheelchair but an August 2019 VA treatment record shows that the Veteran was restricted to a wheelchair and a September 2019 VA treatment record shows that the Veteran was recently restricted to a wheelchair due to recent lower extremity weakness. However, records prior to 2019 show that the Veteran was counseled to engage in regular exercise. The Board finds that the criteria for the higher 40 percent rating under DC 7913 have not been met. The criteria for a higher rating under DC 7913 are conjunctive not disjunctive, i.e., there must be insulin dependence (or oral hypoglycemia agents) and restricted diet and regulation of activities. "Regulation of activities" is defined by DC 7913 as the "avoidance of strenuous occupational and recreational activities." Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). The medical evidence of record demonstrates that, prior to his death, the Veteran's diabetes was treated by diet, insulin and oral hypoglycemic agents. These manifestations meet the criteria for a 20 percent rating. He was not shown to have been instructed by a physician to avoid strenuous occupational and recreational activities, as required for a higher 40 percent rating due to his diabetes. While the Veteran was restricted to a wheelchair due to recent lower extremity weakness sometime in August 2019, this was not directly due to his diabetes. Significantly, records prior to 2019 show that the Veteran was counseled to engage in regular exercise The record also does not establish that the Veteran's disability most nearly approximates the other criteria associated with an increased rating under DC 7913. Review of the VA treatment records also demonstrates that he has not visited his diabetic care provider twice a month. Significantly, the November 2019 VA examination report shows that he visited his VA diabetic care provider less than two times per month. Therefore, the Veteran's diabetes does not most nearly approximate the criteria associated with a 60 or 100 percent evaluation under DC 7913. In light of the foregoing, the evidence is against the assignment of an evaluation higher than 20 percent for the diabetes mellitus under DC 7913 The Board has considered the lay statements regarding the severity of the Veteran's diabetes prior to his death. While the Veteran and his widow are competent to report symptoms of his diabetes, they are not competent to identify a specific level of disability of his diabetes according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's diabetes has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluation. The medical findings (as provided in the examination reports) directly address the criteria under which diabetes is evaluated. For these reasons, the Board finds that the weight of the evidence is against a higher disability rating for diabetes. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7. 3. Neuropathy Ratings of the bilateral upper and lower extremities The Veteran's widow seeks higher disability ratings for the Veteran's service-connected diabetic neuropathy of the bilateral upper and lower extremities prior to his death. By way of history, as above, the Veteran submitted an initial claim for service connection for diabetes in December 2002 and, by rating decision dated in June 2003, the RO granted service connection for diabetes with cataracts, assigning a 20 percent disability rating effective December 1, 2001 based on his presumed exposure to herbicides during his active service in Vietnam. The Veteran submitted a claim for an increased rating for his diabetes in September 2008 and, by rating decision dated in June 2009, the RO granted service connection for neuropathy of the bilateral upper and lower extremities, assigning separate 10 percent disability ratings for the upper extremities effective April 24. 2008 and assigning separate 10 percent disability ratings for the bilateral lower extremities effective November 23, 2007. The Veteran submitted the current claim for an increased rating for his neuropathy in September 2010 and, by rating decision dated in May 2011, the RO continued separate 10 percent disability ratings for the Veteran's bilateral upper extremity neuropathy and increased the Veteran's disability ratings for bilateral lower extremity neuropathy from 10 to 20 percent disabling effective September 28, 2010. The Veteran disagreed with this decision and perfected this appeal. Subsequently, by rating decision dated in March 2021, the RO, in part, increased each of the separate disability ratings for the Veteran's bilateral lower extremity neuropathy from 20 to 40 percent disabling beginning November 12, 2019; increased the disability rating for the Veteran's right upper extremity neuropathy from 10 to 30 percent disabling beginning November 12, 2019; and increased the disability rating for the Veteran's left upper extremity neuropathy from 10 to 20 percent disabling beginning November 12, 2019. Legal Criteria The Veteran's neuropathy of the upper extremities is rated under the provisions of 38 C.F.R. § 4.124a, DC 8615, pertaining to paralysis of the median nerve. Under DC 8615, a 10 percent rating is warranted for mild incomplete paralysis in either the major or minor extremity. For moderate incomplete paralysis in the minor extremity a 20 percent rating is warranted while a 30 percent rating is warranted for moderate incomplete paralysis in the major extremity. For severe incomplete paralysis of the minor extremity a 40 percent rating is warranted while a 50 percent rating is warranted for severe incomplete paralysis of the major extremity. Complete paralysis will be evaluated as 70 percent for the major limb, and 60 percent for the minor limb, for such symptoms as the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. The Veteran's neuropathy of the lower extremities is rated under the provisions of 38 C.F.R. § 4.124a, DC 8520. DC 8520 assigns 10, 20, 40, and 60 percent ratings for incomplete paralysis of the sciatic nerve that is mild, moderate, moderately severe, and severe with marked muscular atrophy, respectively. 38 C.F.R. § 4.124a, DC 8520. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis for a particular nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See 38 C.F.R. § 4.124 (a), Note at "Diseases of the Peripheral Nerves." Peripheral neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Relevant Evidence Evidence relevant to the level of severity of the Veteran's neuropathy of the bilateral upper and lower extremities during the appeal period includes a November 2010 VA general examination as well as a November 2019 VA peripheral nerve examination report. During the November 2010 VA general examination, the Veteran reported that he had experienced symptoms of bilateral numbness and tingling of the hands intermittently, occurring 3 to 5 times per day (worse in the morning), for more than 5 years. These symptoms last minutes to hours and are often resolved with massaging the hands. Additionally, the Veteran experienced numbness and tingling in the lower extremities to above the ankle, intermittent in occurrence with mild decrease in sensation, more often on the right. He denied swelling of the hands/feet, redness, heat, or injury. He did not take any medication for neuropathy of the right or left upper or lower extremities. On physical examination, it was noted that the Veteran's lower extremity strength was normal (5/5), but it was also noted that his deep tendon reflexes were diminished a the patellar (1+) and Achilles (trace). There was mild decreased light touch to the feet across the dorsal aspect of the right and left foot to the ankle. Painful sensation as well as vibration were intact in the lower extremities to the periphery. The examiner diagnosed mild peripheral neuropathy of the bilateral upper and lower extremities. During the November 2019 VA peripheral nerves examination, the examiner continued diagnoses of bilateral upper and lower extremity peripheral neuropathy and noted that the Veteran was right hand dominant. With regard to the upper extremities it was noted that the Veteran experienced intermittent pain, paresthesias and/or dysesthesias, and numbness of a mild severity. With regard to the lower extremities, it was noted that the Veteran experienced mild constant pain as well as intermittent pain, paresthesias and/or dysesthesias, and numbness of a moderate severity. On neurologic examination, the Veteran had slightly abnormal strength for both the upper and lower extremities, described as 4/5 (slightly less than normal strength). The Veteran also had slightly abnormal deep tendon reflexes, described as 1+ (decreased) for the bilateral upper extremities and absent deep tendon reflexes, described as 0 (absent) for the bilateral lower extremities. Light touch/monofilament testing was normal for the shoulders, inner/outer forearms, and hands/fingers; decreased for the knees/thighs and ankles/lower legs; and absent for the feet/toes. Position sense testing was normal for the bilateral upper extremities, decreased for the right lower extremity, and absent for the left lower extremity. Vibration sensation testing was also normal for the bilateral upper extremities, decreased for the right lower extremity, and absent for the left lower extremity. Cold sensation testing was normal for the bilateral upper extremities and decreased for the bilateral lower extremities. There was no muscle atrophy and there were no trophic changes. Significantly, the examiner found that the Veteran experienced incomplete paralysis of the bilateral upper extremities which was of a mild severity. The examiner also found that the Veteran experienced incomplete paralysis of the bilateral lower extremities which was of a moderate severity. There were no other pertinent physical findings. The examiner opined that the Veteran's peripheral nerve condition impacted his ability to work as the Veteran was in a wheelchair, unable to stand or walk on his own, and had weakness of his upper extremities. Also of record are VA treatment records dated through the Veteran's death in January 2020. These records are consistent with the findings of the November 2010 and November 2019 VA examination reports. As above, April 2011 and December 2018 VA treatment records show that the Veteran does not regularly use a wheelchair but an August 2019 VA treatment record shows that the Veteran was restricted to a wheelchair and a September 2019 VA treatment record shows that the Veteran was recently restricted to a wheelchair due to recent lower extremity weakness. Analysis a. A disability rating greater than 10 percent prior to November 12, 2019 and greater than 30 percent thereafter for right upper extremity neuropathy is denied. With regard to the right upper extremity prior to November 12, 2019, the Board finds that a disability rating greater than 10 percent is not warranted. The most probative evidence of record is the November 2010 VA general examination which objectively documented mild upper extremity peripheral neuropathy. As such, the Board will characterize the Veteran's right upper extremity radiculopathy as no more than mild prior to November 12, 2019. With regard to the right upper extremity from November 12, 2019 until the time of the Veteran's death in January 2020, the Board finds that a disability rating greater than 30 percent is not warranted. Significantly, the November 2019 VA peripheral nerves examiner specifically characterized the Veteran's right upper extremity neuropathy as mild incomplete paralysis. While the November 2019 VA examination does show some loss of strength as well as a reduction in deep tendon reflexes, there was no evidence of muscle atrophy and/or trophic changes. As such, the Board finds that there was no indication of severe incomplete paralysis of the right upper extremity prior to the Veteran's death. b. A disability rating greater than 10 percent prior to November 12, 2019 and greater than 20 percent thereafter for left upper extremity neuropathy is denied. With regard to the left upper extremity (the Veteran's minor extremity) prior to November 12, 2019, the Board finds that a disability rating greater than 10 percent is not warranted. The most probative evidence of record is the November 2010 VA general examination which objectively documented mild upper extremity peripheral neuropathy. As such, the Board will characterize the Veteran's left upper extremity radiculopathy as no more than mild prior to November 12, 2019. With regard to the left upper extremity from November 12, 2019 until the time of the Veteran's death in January 2020, the Board finds that a disability rating greater than 20 percent is not warranted. Significantly, the November 2019 VA peripheral nerves examiner specifically characterized the Veteran's left upper extremity neuropathy as mild incomplete paralysis. While the November 2019 VA examination does show some loss of strength as well as a reduction in deep tendon reflexes, there was no evidence of muscle atrophy and/or trophic changes. As such, the Board finds that there was no indication of severe incomplete paralysis of the left upper extremity prior to the Veteran's death. c. A disability rating of 40 percent, and no higher, for right lower extremity neuropathy is granted effective August 30, 2019; a disability rating greater than 20 percent prior to August 30, 2019 for right lower extremity neuropathy is denied. Upon review of the evidence, the Board finds that a disability rating of 40 percent is warranted for right lower extremity neuropathy beginning August 30, 2019. As above, an August 30, 2019 VA treatment record shows that the Veteran was restricted to a wheelchair and a September 2019 VA treatment record shows that this restriction was due to recent lower extremity weakness. Such is evidence of moderately severe incomplete paralysis warranting a 40 percent disability rating under DC 8520. With regard to the potential for a higher disability rating for the right lower extremity prior to August 30, 2019, the Board finds that a disability rating greater than 20 percent is not warranted. The most probative evidence of record is the November 2010 VA general examination which objectively documented no more than moderate right lower extremity peripheral neuropathy. As such, the Board will characterize the Veteran's right lower extremity radiculopathy as no more than moderate prior to August 30, 2019. With regard to the right lower extremity for the time period beginning August 30, 2019 until the time of the Veteran's death in January 2020, the Board finds that a disability rating greater than 40 percent is not warranted. Significantly, while the Veteran was restricted to a wheelchair due to his lower extremity weakness beginning August 30, 2019, as above, the November 2019 VA peripheral nerves examination is negative for muscle atrophy which is required for a higher rating under DC 8520. As such, the Board finds that a disability rating greater than 40 percent is not warranted for the Veteran's right lower extremity from August 30, 2019 to the time of his death. d. A disability rating of 40 percent, and no higher, for left lower extremity neuropathy is granted effective August 30, 2019; a disability rating greater than 20 percent prior to August 30, 2019 for left lower extremity neuropathy is denied. Upon review of the evidence, the Board finds that a disability rating of 40 percent is warranted for left lower extremity neuropathy beginning August 30, 2019. As above, an August 30, 2019 VA treatment record shows that the Veteran was restricted to a wheelchair and a September 2019 VA treatment record shows that this restriction was due to recent lower extremity weakness. Such is evidence of moderately severe incomplete paralysis warranting a 40 percent disability rating under DC 8520. With regard to the potential for a higher disability rating for the left lower extremity prior to August 30, 2019, the Board finds that a disability rating greater than 20 percent is not warranted. The most probative evidence of record is the November 2010 VA general examination which objectively documented no more than moderate left lower extremity peripheral neuropathy. As such, the Board will characterize the Veteran's left lower extremity radiculopathy as no more than moderate prior to August 30, 2019. With regard to the left lower extremity for the time period beginning August 30, 2019 until the time of the Veteran's death in January 2020, the Board finds that a disability rating greater than 40 percent is not warranted. Significantly, while the Veteran was restricted to a wheelchair due to his lower extremity weakness beginning August 30, 2019, as above, the November 2019 VA peripheral nerves examination is negative for muscle atrophy which is required for a higher rating under DC 8520. As such, the Board finds that a disability rating greater than 40 percent is not warranted for the Veteran's left lower extremity from August 30, 2019 to the time of his death. 4. An initial disability rating of 70 percent prior to November 4, 2019 for PTSD with secondary depression is granted. A rating greater than 70 percent is denied. The Veteran's widow seeks higher disability ratings for the Veteran's service-connected PTSD prior to his death. By way of history, the Veteran submitted an initial claim for service connection for PTSD in September 2010. By rating decision dated in May 2011, the RO granted service connection for PTSD with secondary depression, assigning a 30 percent rating effective September 28, 2010. The Veteran disagreed with this decision and perfected this appeal. Subsequently, by rating decision dated in March 2021, the RO increased he Veteran's disability rating for his PTSD from 30 to 70 percent disabling effective November 4, 2019. Legal Criteria The criteria for evaluating PTSD are found at 38 C.F.R. § 4.130, DC 9411. A 30 percent rating 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands, impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficultly in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss for names of close relatives, own occupation, or own name. The symptoms listed above serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126 (a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). Relevant Evidence Evidence relevant to the level of severity of the Veteran's PTSD since the grant of service connection and prior to his death includes VA psychiatric examination reports dated in November 2010 and November 2019. During the November 2010 VA examination, the Veteran reported experiencing poor sleep (trouble falling and staying asleep), nightmares (several nights each week related to his experience in Vietnam), flashbacks, problems with his memory and concentration, difficulty focusing his attention, problems with anger/irritability, limited coping skills, feeling quick to anger, depression, and a strong startle response to loud noises such as a jet engine. He had been treated at a VA outpatient clinic for his psychiatric problems but, more recently, began getting treatment through a Vet Center as well as a private psychologist and was recently diagnosed with PTSD. He denied the use of psychotropic medications. The Veteran reported that he recently worked as the director of a nonprofit organization but retired approximately one year earlier. Prior to retiring from work, he got along well with his coworkers and there was no history of missing any time from work. The Veteran had been married for 30 years and had three grown children, two from his first marriage and one from his second marriage. He had a good relationship with his wife but did not maintain contact with his three grown children. He denied the use of alcohol/drugs. On mental status examination, the Veteran was neatly/casually dressed and was cooperative throughout the evaluation process. His affect was controlled and appropriate. He was willing to respond to questions. His recent, intermediate, and remote memory were intact. There was no indication of hallucinations or delusions. He was oriented times three and alert. He appeared to be mildly anxious as the interview progressed. His eye contact was good and his thinking was clear. His speech was normal in rate, rhythm, and volume. He appeared to be a fair to good personal historian. His fund of general information was average. Judgments were appropriate and abstract in the testing situation. There was no evidence of psychotic or delusional processes. His thoughts were clear, logical, goal directed, and linear. Mood and affect were sad and depressed. Insight and judgment appeared to be within normal limits. Intellectual level of functioning was average. No gross cognitive deficits were noted. Attention and concentration were intact. No bizarre or unusual behaviors were observed during the interview. Upon review of the claims file, the examiner noted that the Veteran has experienced significant social impairment due to his symptoms of PTSD. Specifically, his PTSD symptoms have interfered with his ability to function affectively in social situations because of his difficulty controlling his anger and his irritability. He has difficulty establishing and maintaining intimate social relationships. His PTSD symptoms have also decreased his work efficiency and his ability to perform occupational tasks. As above, due to his PTSD, the Veteran had difficulty controlling his anger and his irritability. Furthermore, the Veteran's symptoms of PTSD have impaired his thought process and ability to effectively communicate with others. During the November 2019 VA examination, the examiner continued a diagnosis of PTSD and noted that, while the Veteran may experience some depression, the Veteran did not meet the criteria for a separate diagnosis of depression. Significantly, the examiner opined that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran continued to reside with his wife of 30 plus years. It was noted that the Veteran's family belonged to the Choctaw Nave tribe and that the Veteran was currently the chief of this tribe and was wheelchair dependent. The Veteran's PTSD resulted in the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty adapting to stressful circumstances, including work or a work like setting. Also of record are VA treatment records dated through the Veteran's death in January 2020. These records are consistent with the findings of the November 2010 and November 2019 VA examination reports. Analysis Upon review of the above evidence, the Board finds that a disability rating of 70 percent is warranted for the Veteran's PTSD since the grant of service connection effective September 28, 2010. As early as the November 2010 VA examination, it was noted that the Veteran experienced significant social and occupational impairment due to his symptoms of PTSD, including difficulty controlling his anger and his irritability. Furthermore, the November 2010 VA examiner noted that the Veteran's PTSD symptoms had impaired his thought process and ability to effectively communicate with others. Such impairment supports a finding that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood since the grant of service connection until the Veteran's death in January 2020. As for the potential of a disability rating higher than 70 percent, the Board finds that, prior to his death, the evidence does not show the symptomatology required for a 100 percent rating. The Board has looked at all the factors and evidence identified above to determine whether the Veteran has met or more closely approximated the criteria for a maximum 100 percent rating. However, when considering the overall evaluation of the examples which may support the 100 percent rating, the frequency, duration and severity of symptoms, the Veteran's capacity for adjustment, and the examiner's assessments of the Veteran's overall psychological, social and occupational functioning, the Board must conclude that the Veteran's psychiatric disability has not met or more closely approximated the criteria for a 100 percent rating at any relevant time. In this respect, prior to his death, the Veteran, even at his worst, could efficiently converse with the VA examiner, and while he did require assistance with managing his daily activities, this was due to physical and not mental disability. He was not psychotic or out of touch with reality. Overall, his psychiatric disorder was not shown to manifest the type, extent and severity of symptoms demonstrating "total occupational and social impairment" within the meaning of the rating schedule at any point pertinent to this appeal. As such, a disability rating of 70 percent, and no higher, is warranted for the Veteran's PTSD prior to his death. 5. A TDIU is granted. A total disability rating may be assigned when the schedular rating is less than 100 percent where a Veteran is 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, that disability is rated 60 percent or more, or if there are two or more disabilities, there shall be at least one disability rated 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Prior to his death, the Veteran had established service connection for the following: PTSD with secondary depression, rated 70 percent disabling; right knee arthritis with limited range of motion, status post total right knee replacement, rated 60 percent disabling; degenerative arthritis with intervertebral disc syndrome, postoperative, rated 40 percent disabling; left lower extremity neuropathy, rated 40 percent disabling; right lower extremity neuropathy, rated 40 percent disabling; right upper extremity neuropathy, rated 30 percent disabling; diabetes, rated 20 percent disabling; bilateral cataracts, rated 20 percent disabling; left upper extremity neuropathy, rated 20 percent disabling; left knee arthritis, rated 10 percent disabling; right middle finger disability, rated noncompensably disabling; and scars of the right knee, rated noncompensably disabling. Pertaining to the current appeal period beginning, the Veteran's combined rating for compensation purposes was 90 percent beginning September 28, 2010 and was 100 percent beginning November 12, 2019. Therefore, pertinent to the appeal period prior to his death, the Veteran met the threshold criteria for a TDIU. 38 C.F.R. § 4.16(a). The remaining inquiry is whether he was unable to secure or follow substantially gainful occupation due solely to service-connected disabilities prior to his death. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A review of the record shows that the Veteran last worked full-time in December 2008 as the director of a nonprofit organization. It also appears that the Veteran's family belonged to the Choctaw Nave tribe and that the Veteran was the chief of this tribe during the November 2019 VA examination. However, there is no indication that the Veteran received any compensation for this position. As above, the November 2019 VA knee and peripheral nerve examiners opined that the Veteran's service-connected disabilities impacted his ability to work as the Veteran was unable to stand or walk on his own and had weakness of his upper extremities. Furthermore, both the November 2010 as well as the November 2019 VA psychiatric examiners found that the Veteran's service-connected PTSD impacted his ability to work due to resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Also, a November 2019 VA examiner noted that the Veteran uses a wheelchair, needs driving assistance, and has had in home care September of 2019. According to the examiner, the Veteran cannot fully commit to his normal living needs, and needs assistance with cooking and bathing. Also, his wife had to drive him to his appointment. As such, the Veteran's inability to take care of himself on his own would heavily affect and limit his ability to work in any form. Unemployability is a factual determination, not a medical one. The Board is tasked with, first, reviewing the medical evidence to glean the Veteran's service-connected impairment, and second, determining as a legal matter whether that impairment is sufficient to render her unable to maintain substantially gainful employment. As above, the November 2010/November 2019 VA psychiatric examiners found that the Veteran's service-connected psychiatric disability results in psychiatric symptoms which would make it very difficult for him to work. This suggests that sedentary employment was precluded prior to the Veteran's death. Also, the November 2019 VA knee and peripheral nerve examiners found that the Veteran's service-connected disabilities impacted his ability to perform physical work. This suggests that physical employment is also precluded. While not definitive, such findings support the Veteran's assertion that, prior to his death, his service-connected disabilities affected his ability to secure substantially gainful employment. Therefore, the Board finds that it is at least as likely as not that the Veteran was unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities prior to his death and, therefore, a TDIU is warranted. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board April Maddox, 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.