Citation Nr: 0005973 Decision Date: 03/06/00 Archive Date: 03/14/00 DOCKET NO. 99-00 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for residuals of a service-connected shell fragment wound to the right lower extremity, with damage to the right femoral nerve and Muscle Group XV. 2. Entitlement to an evaluation in excess of 30 percent for service-connected post-traumatic stress disorder (PTSD). 3. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The veteran and C.R. ATTORNEY FOR THE BOARD J.M. Daley, Associate Counsel INTRODUCTION The veteran had active service from October 1967 to November 1969, to include service in the Republic of Vietnam. His awards and medals include the Combat Infantryman's Badge and Purple Heart Medal, indicative of his participation in combat with the enemy. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in February and October 1998 from the Department of Veterans Affairs (VA) Regional Office (RO), located in Winston-Salem, North Carolina, in which the RO denied increased evaluations for a service-connected right lower extremity shell fragment wound and for PTSD, and also denied TDIU. In a decision dated in October 1998, the RO denied service connection for a disorder affecting the right hand, and notified the veteran of such that same month. The veteran did not appeal that determination. See 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302 (1999). FINDINGS OF FACT 1. Residuals of the service-connected shell fragment wound to the right lower extremity consist of weakness, pain and sensory changes in the right lower extremity due to incomplete right femoral nerve paralysis, some limitation of hip motion and asymptomatic scarring. 2. The entire competent and probative evidence of record shows that PTSD is manifested by no more than occupational and social impairment with reduced reliability and productivity due to symptoms such as circumstantial speech, impaired judgment and abstract thinking, motivation and mood disturbances, and difficulty in establishing or maintaining effective work and social relationships. 3. Service connection is in effect for residuals of a shell fragment wound to the right lower extremity, evaluated as 30 percent disabling; and for PTSD, also evaluated as 30 percent disabling. The veteran has no other adjudicated service- connected disabilities. 4. The veteran left school in the 11th grade. He has work experience in a manufacturing plant and last worked there in August 1990. 5. The competent and probative evidence does not show that the veteran's service-connected disabilities, in and of themselves, are of sufficient severity as to prevent him from engaging in some form of substantially gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation in excess of 30 percent for residuals of a service-connected shell fragment wound to the right lower extremity, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Code 8526 (1999). 2. The criteria for an evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). 3. The criteria to warrant entitlement to TDIU benefits have not been met. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service medical records reflect that in July 1968, the veteran was hit by a booby trap fragment in the right femoral area. Records indicate that there was no nerve involvement due to the initial injury. The veteran underwent surgical repair of the right common femoral artery and debridement of the wound. Neurologic examination later in July 1968 revealed a paralysis of the knee extensors; diagnoses included right femoral nerve palsy secondary to laceration of the right femoral artery. The veteran underwent physical therapy during service. In August 1968, the right thigh incision was noted to be well-healed and femoral pulses were strong; the impression was successful repair of the right common femoral artery. Service records reflect that electromyography revealed denervation of the right quadriceps; examination showed right quadriceps atrophy and hamstring tightness, with zero quadriceps strength. The femoral nerve palsy was opined to be incomplete, primarily affecting the quadriceps femoris. In October 1968, the veteran underwent surgical exploration of the femoral nerve, with a freeing of the adherent scar tissue around the femoral artery. The repair was noted to be successful and treatment notes indicate that the veteran had minimal ambulatory disability thereafter. Entries dated in February and March 1969 reveal the veteran's complaints of pain at his wound site. X-rays of the right knee taken in March 1969 revealed spotty osteoporotic changes. The report of medical examination at separation, dated in November 1969, notes hypesthesia of the right leg. In February 1970, the veteran appeared for a VA examination. X-rays were negative for abnormal skeletal changes or evidence of a retained foreign body in the right thigh. The VA examiner noted a history of "rather severe" muscle damage and fracture of the femur as a result of the service injury. The veteran complained of right thigh and upper leg pain, and right knee buckling. The veteran walked in a normal manner and the examiner was unable to detect any right lower extremity shortening. Motion of the right hip, knee and ankle were stated to be completely normal. Thigh circumferences were equal. The shrapnel wound scar was stated to be somewhat adherent, but not particularly tender and well healed. The examiner indicated that there was no evidence of damage to Muscle Group XIV. Nor was any bone damage found upon examination at that time. Neurologic examination revealed some moderate weakness in quadriceps flexion, and a diminished right-sided knee jerk. The neurologic examiner described the veteran's disability as moderately severe, due to right femoral neuropathy manifested by weakness of the quadriceps and an absence of knee jerk. An attached hospital summary, showing hospitalization from December 1969 to January 1970, indicates the presence of "marked quadriceps atrophy." The veteran's weakness and pain in the anterior aspect of the right thigh were thought to be the result of disuse atrophy for which he was sent for therapy. In a rating decision dated in March 1970, the RO established service connection for the veteran's right lower extremity shell fragment wound residuals, assigning a 30 percent evaluation effective November 22, 1969; a temporary total convalescent rating from December 19, 1969 to January 31, 1969, with a 30 percent evaluation resuming thereafter. The veteran was hospitalized at a VA facility from March to April 1991, with diagnoses of alcohol dependence and mixed substance abuse as well as a history of PTSD with depression. He was noted to have questionable alcoholic peripheral neuropathy in the upper extremities. A July 1991 report of VA neuropsychiatric examination indicates that the veteran's mood was calm and his affect appropriate during the interview. He evidenced no bizarre motor movements or tics, no delusions, no loose associations, no ideas of reference and no suspiciousness. He was fully oriented and both his recent and remote memory were opined to be "good." His insight and judgment were stated to be adequate. Psychologic testing was recommended. In August 1991, the veteran reported for a VA psychologic examination. He complained of flashbacks, sleeping difficulty and a dislike of being around people. He reported that he had been unemployed since July 1990 and separated from his spouse of 19 years since August 1990. He stated that he left school in the 11th grade. He stated that his use of alcohol and drugs stemmed primarily from his attempts to control the distress associated with his Vietnam experiences. He reported problems maintaining his stability and sobriety. He was unsure of dates and indicated that his memory was "shot." He complained of the "nearness of his memories" and his emotional confusion relating to combat experiences. He reported avoiding people and anything that could trigger his memories. He reported having fights and recognizing that his emotional instability created problems with his spouse and his work. He appeared anxious and distressed throughout the interview. The examiner noted that a tremor was often evidenced. The veteran's attention span was brief and he "struggled to calm himself sufficiently so he could focus on the material and tasks at hand." On psychologic testing performed in August 1991, the veteran performed in the borderline to mentally deficient range. His long-term memory skills were opined to be limited and the examiner noted that the "overall distribution of [the veteran's] intellectual abilities would suggest that his work opportunities might be limited...would probably work more comfortably in situations where verbal skills are less important and perceptual motor skills more highly valued." The examiner noted that the veteran felt "ill prepared" to deal with environmental pressures and stresses, and that the impulse to withdraw was strong. The examiner discussed the veteran's "self-imposed isolation." The examiner stated that the veteran maintained little interest in daily activities and noted that the veteran was easily angered, complicating his social interaction. The veteran also reported a variety of somatic concerns and stated that "pessimism prevails." He reported experiencing unusual thought content, purportedly hearing strange things when alone, and having bizarre sensory experiences, stating that his "soul sometimes leaves my body." Cognitive processing skills were opined to be impaired, with difficulties in sustained concentration, memory skills and attention. The August 1991 psychologic examiner summarized a "persistent level of arousal that is reflected through significant sleep problems, a startle response, irritability, and concentration problems." Psychiatric examination revealed no bizarre motor movements, no delusions, loose associations, or ideas of reference or suspiciousness. The veteran's mood was calm and his affect was appropriate. In a rating decision dated in September 1991, the RO established service connection and assigned a 10 percent evaluation for PTSD, effective April 10, 1991. X-rays taken in December 1992 showed bilateral genu varum. In September 1993, a VA neuropsychiatric consultant noted that the veteran was moderately anxious and had mild depression and mild psychomotor retardation. The veteran seemed hesitant and withdrawn, but did not evidence hallucinations, delusions, paranoia, or ideas of reference, and was not psychotic. In a rating decision dated in February 1994, the RO increased the evaluation for PTSD from 10 to 30 percent, effective December 17, 1992. A June 1997 VA outpatient record notes a "drop leg." That record indicates that the veteran had severe peripheral neuropathy of questionable etiology, stated to probably be alcohol related. A VA outpatient treatment note dated in August 1997 indicates that the veteran was losing function in his right upper extremity In October 1997, the veteran reported for a VA examination. A peripheral nerve evaluation was conducted. The veteran refused to walk without his cane. He was able to stand on his toes, momentarily using his cane. He was unable to jog or squat. His thighs were of equal size. There was bilateral weakness with foot dorsiflexion, but other lower extremity muscles were within normal range. Sensory testing was stated to be difficult to evaluate, with light touch recognized in all extremities on most occasions. Joint sense was stated to be "especially poor in the right toes" and mildly impaired in the left toes. The diagnoses included diffuse areflexia and spotty sensory loss in all extremities. In July 1998, the veteran underwent orthopedic evaluation by a private physician. He complained of his right leg giving out. He reported being unable to bend, stoop or walk without help, depending on his family for support. He reported symptoms of tingling and numbness in the right leg, and also in his arm and hand. He stated that the pain was constant and not helped by medication or treatment. The examiner noted that the veteran was unable to walk without individual assistance form another person. The examiner noted that the muscle group affected was the quadriceps muscles, basically the anterior thigh group, and that such affected the range of the veteran's hip motion. There was sensitivity and tenderness to the scar, without keloid formation. The examiner noted some tendon and muscle damage as well as nerve damage. The veteran did not wear any truss. Muscle strength of the anterior thigh complex was stated to be a "2." The veteran had right hip flexion to 60 degrees, extension to 10 degrees, internal rotation to 20 degrees, external rotation to 30 degrees and hip joint pain, fatigue and weakness at 10 degrees extension, internal and external rotation. Neurologic examination revealed decreased sensation on the right leg and foot and the left anterior thigh, as well as decreased vibration sense on both feet, consistent with a peripheral neuropathy with decreased pinprick to the left leg in the femoral nerve distribution. The veteran denied alcohol abuse in his past; however the examiner noted the veteran's history of alcoholic neuropathy. X-rays were stated to showed osteoporosis and mild degenerative arthritis of the pelvis, right hip and right femur. Objective factors were noted to be an entrance wound and a surgical wound, as well as weakness of the anterior thigh muscle group and decreased range of motion with decreased sensation to pinprick in the distribution the femoral nerve and right lower extremity. The examiner additionally commented that the veteran had muscle atrophy and contractures of the hands, and problems with motor and sensory peripheral neuropathy both the upper and lower body, "which seems to add to his debilities." The examiner summarized that the veteran's decreased hip motion, and muscle and nerve damage to the lower extremity, added to his motor and sensory peripheral neuropathy and Dupuytren' contractures, "all of which make it impossible for him to be productively employed." In July 1998, the veteran underwent private psychiatric examination. He described intrusive memories, and frequent nightmares and flashbacks. He reported avoiding thoughts and activities reminding him of warfare, and complained of a restricted affect, a morbid outlook, hyperarousal symptoms, insomnia, decreased concentration, hypervigilance and an intense startle reflex. He stated that he was frequently withdrawn, sad and tearful. His brother accompanied him to the interview and stated that the veteran was frequently suicidal; the veteran denied current suicidal ideation. The veteran reported that he had not had a drink in the past four months. He gave a history of 19-years employment at the same company, and stated that eight years earlier he had stopped working secondary to neurologic problems affecting his arm and leg. He reported having few friends. He was alert and fully oriented. His speech was normal. His affect was slightly dysphoric, but overall fairly euthymic. He smiled at times. His thought process was linear and unimpaired. There was no evidence of delusions or hallucinations, other than flashbacks. The veteran described chronic suicidal ideation without active suicidal thoughts. The examiner noted that the veteran maintained basic personal hygiene and did not exhibit in appropriate behaviors during the examination. There was no evidence of obsessive or ritualistic behavior. There were no signs or symptoms of panic attacks. There was evidence of mild anxiety and moderate-to-severe depression. There was some evidence of impaired impulse control: The veteran's brother described him as frequently getting very agitated and frustrated, at one point inflicting heavy damage to his vehicle. The veteran also described chronic sleep impairment with a decrease in energy interfering with his daily activities. The diagnoses included PTSD, with an assigned GAF of 60. The VA examiner summarized that the veteran had moderate-to- severe symptoms of PTSD for which treatment was recommended. The examiner commented that the veteran appeared overly isolated with few friends and that "PTSD may have worsened his ability to function adequately at a job." The examiner indicated that with treatment the veteran "may be able to better function both at home and potentially at work." In a September 1998 statement the veteran's former employer reported that the veteran had worked for that company from 1972 to 1990, that he had worked 8 hours of day, 40 hours a week, and that he had resigned. In a decision dated in October 1998, the RO denied TDIU. The veteran testified before the undersigned member of the Board in September 1999. Pertinent to his PTSD he complained of having bad dreams about Vietnam, waking up in cold or hot sweats, and of experiencing panic attacks, being nervous all the time. Transcript at 3-5. C.R., his brother, reported that the veteran had panic attacks three times a week, and also stated that the veteran had gone through periods of suicidal thoughts. C.R. further indicated that the veteran's symptoms were getting worse in recent years. Transcript at 5-7. The veteran reported that he had difficulty remembering things and stated that he got nervous even around family members. Transcript at 7-8. He stated that he did not associate much with neighbors but saw his children and grandchildren, as well as C.R. Transcript at 23. Pertinent to his leg, the veteran reported seeing a physician every three months. Transcript at 9. He complained of right leg weakness and pain, with balance problems. Transcript at 10- 13. He stated that he quit his job in August 1990 due to fear that he would not be able to perform his duties controlling the movement of machinery safely. Transcript at 14. He also reported having had problems with the foreman, to include having struck him. Transcript at 19. C.R. reported that the veteran's leg numbness caused him to fall sometimes, and indicated that physician had noted a "drop leg." Transcript at 15-16. The veteran denied recent hospitalizations for his leg. Transcript at 26. He reported that he did not like to drive, but was able to use the brake and gas pedals. Transcript at 27. Generally Applicable Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4 (1999). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1, 4.2 (1999), which require the evaluation of the complete medical history of the veteran's condition. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter the benefit of the doubt in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (1999). In determining the proper rating to be assigned for a given disability, the Board may only consider those factors which are included in the rating criteria provided by regulations for rating that disability. To do otherwise would be error as a matter of law. Drosky v. Brown, 10 Vet. App. 251 (1997); Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). Introductory Matters In general, allegations of increased disability are sufficient to establish well-grounded claims seeking increased ratings. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). In the instant case, there is no indication that there are additional records which have not been obtained and which would be pertinent to the present claims. Thus, no further development is required in order to comply with VA's duty to assist mandated by 38 U.S.C.A. § 5107(a). Shell Fragment Wounds Rating Criteria Evaluation of injury includes consideration of resulting impairment to the muscles, bones, joints and/or nerves, as well as the deeper structures and residual symptomatic scarring. See 38 C.F.R. §§ 4.44, 4.45, 4.47, 4.48, 4.49, 4.50, 4.51, 4.52, 4.53, 4.54 (1999). Limitation of motion of the thigh, and other thigh impairment is evaluated under 38 C.F.R. § 4.71a. Diagnostic Code 5251 (1999) provides for a 10 percent evaluation where thigh extension is limited to five degrees. Diagnostic Code 5252 (1999) provides for a 10 percent evaluation where flexion is limited to 45 degrees. Diagnostic Code 5253 (1999) provides for a 10 percent evaluation where a veteran is unable to toe out more than 15 degrees due to limitation of rotation of the affected leg. 38 C.F.R. § 4.71a. Muscle Group damage is categorized as mild, moderate, moderately severe and/or severe and evaluated accordingly. See 38 C.F.R. § 4.56(d). Muscle Group XIV affects knee extension and the simultaneous flexion of the hip and the knee. Muscle Group XIV also acts with Muscle Group XVII in postural support of the body, and acts with the hamstrings in synchronizing hip and knee motion. 38 C.F.R. § 4.73, Diagnostic Code 5314 (1999) provides for ratings from zero to 40 percent for impairment of Muscle Group XIV. Muscle Group XV affects hip adduction and flexion. 38 C.F.R. § 4.73, Diagnostic Code 5315 (1999) provides for ratings from zero to 30 percent for impairment of Muscle Group XV. 38 C.F.R. § 4.55(a) (1999) provides that a muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804 and 7805 (1999) pertain to scars. A 10 percent evaluation is warranted for superficial, poorly nourished scars with repeated ulceration under Diagnostic Code 7803. Diagnostic Code 7804 provides that a 10 percent disability evaluation is warranted for superficial scars that are tender and painful on objective demonstration. Diagnostic Code 7805 otherwise provides that a rating for scars is based upon the limitation of function of the affected part. 38 C.F.R. § 4.118. The term "incomplete paralysis" indicates impairment of function of a degree substantially less than the type of picture for complete paralysis given for each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, Note (1999). Incomplete paralysis of the femoral nerve warrants assignment of a 30 percent evaluation where severe, a 20 percent evaluation where moderate, and a 10 percent evaluation where mild. 38 C.F.R. § 4.124a, Diagnostic Code 8526. A 40 percent evaluation is assigned where there is complete paralysis of the quadriceps extensor muscles. Id. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (1999). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Analysis The veteran is currently in receipt of a 30 percent evaluation, assigned under 38 C.F.R. § 4.124a, Diagnostic Code 8526, based on severe, incomplete paralysis of the femoral nerve. That diagnostic code provides for a higher evaluation, 40 percent, where there is complete paralysis of the quadriceps extensor muscle. Service medical records clearly indicate only incomplete femoral nerve paralysis. Moreover, the report of VA examination conducted shortly after service discharge, indicates only moderate disability in the form of weakness and an absent knee jerk from right femoral neuropathy, and does not indicate total paralysis. Nor did VA examinations conducted in October 1997 or July 1998 indicate complete femoral nerve paralysis to warrant assignment of a 40 percent evaluation under Diagnostic Code 8526. Although the veteran has argued that a physician has noted a "drop leg," and a June 1997 VA outpatient record does include note of such, that record indicates that the veteran has severe peripheral neuropathy probably alcohol related. Notably, other records of treatment and evaluation note peripheral neuropathy affecting all four extremities. What the competent evidence does not show is that the veteran's service-incurred shell fragment wound resulted in complete femoral nerve paralysis. To the contrary, the competent evidence contemporary with the shell fragment injury, as well as the medical reports specifically evaluating the residuals of such, are consistent in showing only incomplete paralysis. A 30 percent evaluation is the maximum available under the schedule for incomplete paralysis; thus, a 40 percent evaluation is not warranted by application of Diagnostic Code 8526. Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4 (1999, whether or not they were raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the Board finds no basis upon which to assign a higher disability evaluation. Specifically, the Board has considered the diagnostic codes relevant to muscle injury, motion limitation and scarring. See 38 C.F.R. §§ 4.56, 4.71a, 4.73, 4.118. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case application of 38 C.F.R. §§ 4.56, 4.71a, 4.73, 4.118, is inappropriate and/or fails to result in assignment of a higher percentage evaluation, as further discussed below. Service records created in conjunction with the veteran's original injury do not document any injury to the right leg muscles. Despite noting a history of "rather severe" muscle damage, the February 1970 VA examiner concluded that there was no disability due to muscle damage, but rather, and consistent with service records, that the veteran demonstrated quadriceps weakness and atrophy due to neuropathy and disuse. That examiner's note of muscle damage appears to be based on the veteran's history and not on review of service records. The October 1997 VA examination report notes the veteran's weakness and sensory impairment but states that they are due to neuropathy, not muscle damage. In July 1998, the VA examiner did note that the muscle group affected was the anterior thigh group, but noted such insofar as the veteran's injury affected his range of hip motion. That examiner did not identify pathology attributable to muscle damage. The stated ranges of hip/thigh motion shown in the competent evidence of record, do not meet the criteria for even a compensable evaluation under 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252, 5253. Furthermore, 38 C.F.R. § 4.55(a) provides that a muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. In this case, the function affected is the same, i.e., motion of the right hip/thigh and ambulation. See also 38 C.F.R. § 4.14 (1999); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Finally, the Board acknowledges that the July 1998 examiner noted some sensitivity and tenderness to the veteran's scar area. The objective factors of the veteran's disability, however, were noted to be primarily weakness, pain and sensory changes in the femoral nerve distribution, without separate disability identified as resulting from the veteran's scars. Id. Also, the Board notes that where a diagnostic code is not predicated on a limited range of motion alone, such as Diagnostic Code 8526, the provisions of 38 C.F.R. §§ 4.40 and 4.45 (1999), with respect to functional loss due to pain, do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Based on the above, no increased evaluation is warranted under the Schedule. Additionally, the Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. § 3.321(b)(1) is in order. The evidence in this case fails to show that the veteran's right femoral nerve impairment, in and of itself, now causes or has in the past caused marked interference with his employment, or that such has in the past or now requires frequent periods of hospitalization rendering impractical the use of the regular schedular standards. Id. Rather, post-service the veteran was able to continue working, without requiring frequent surgeries, hospitalization or prolonged time off from work due to his right leg. To the extent the veteran argues that he requires the use of crutches, or assistance for ambulation, the competent evidence of record suggests additional disability due to nonservice-connected alcoholic neuropathy, and does not indicate that the veteran is unable to ambulate due solely to his service-connected shell fragment wound. The veteran's arguments pertinent to unemployability are discussed herein below as pertaining to his TDIU claim. PTSD Rating Criteria Regulations provide that a 30 percent evaluation is to be assigned 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 to be assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships). A 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; a persistent danger of hurting self or others; an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999) The Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health- illness." [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS 32 (4th ed. 1994)]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); also cited in Richard v. Brown, 9 Vet. App. 266 (1996). Analysis The veteran is currently evaluated as 30 percent disabled from PTSD. The 30 percent criteria under Diagnostic Code 9411 contemplate disability due to such symptoms as a depressed mood, anxiety, suspiciousness, weekly or less frequent panic attacks, chronic sleep impairment and/or mild memory loss. The Board looks primarily to the most recent report of VA examination, dated in July 1998, as the most probative medical evidence of the veteran's existing level of disability. See Francisco, supra. At that time, the veteran was fully oriented and alert, without abnormalities of speech or any evidence of delusions or hallucinations. The examiner noted that overall the veteran's mood was euthymic. The veteran has maintained basic hygiene, as noted in examination reports of record. Neither at the time of examination in July 1998, nor in connection with other evaluations did the veteran exhibit inappropriate or obsessive ritualistic behaviors during the interview. Although the veteran's brother reported frequent suicidal ideation and a period of impulse control impairment manifested by agitation and frustration resulting in damage to a vehicle, the veteran denied suicidal ideation at the time of the examination and neither he nor his brother reported the veteran having caused injury to himself or others or posing a threat of doing so. The July 1998 examiner noted only mild anxiety and opined that there was moderate-to-severe depression, summarizing the veteran's impairment from PTSD as moderate-to-severe. That examiner assigned a GAF of 60, indicative of moderate impairment. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); also cited in Richard v. Brown, 9 Vet. App. 266 (1996). The July 1998 examination report does not support evidence of circumstantial, circumlocutory, stereotyped, illogical, obscure or irrelevant speech. Nor does it endorse any difficulty in understanding complex commands; or impairment of both short- and long-term memory, certainly not showing any memory loss for information personal to the veteran. Although the veteran, by history, indicates problems with suicidal ideation and panic attacks, the VA examiner noted symptoms of a nature and degree most consistent with moderate impairment due to PTSD, with episodes of more serious symptomatology. Although the examiner noted the veteran to be isolated, having "few friends", he evidently maintains relationships with family members. Also, the veteran himself reported that he stopped working due to neurologic problems and not PTSD. A review of prior evaluations is consistent: In September 1993 the veteran was described as moderately anxious and mildly depressed. Examination in July 1991 revealed anxiety and concentration difficulties, with noted arousal disturbances. However, the veteran's mood was calm and he was without evidence of delusions, loose association, ideas or reference, suspiciousness or other behaviors affecting his ability to function independently. When the demonstrated symptomatology is considered in tandem with the most recent GAF score of 60, such findings are not sufficient to warrant assignment of more than a 30 percent evaluation under Diagnostic Code 9411. As such, the veteran's claim is denied. TDIU Criteria Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the 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, such disability shall be ratable as 60 percent or more and 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). Before a total rating based upon individual unemployability may be granted, there must also be a determination that the veteran's service- connected disabilities are sufficient to produce unemployability without regard to advancing age or nonservice-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15 (1999). The provisions of 38 C.F.R. § 4.16(b) allow for extraschedular consideration of cases in which veterans who are unemployable due to service-connected disabilities but who do not meet the percentage standards set forth in 38 C.F.R. § 4.16(a). In evaluating whether the veteran's service-connected disability precludes substantially gainful employment, the Board notes that the VA Adjudication Manual, M21-1, Paragraph 50.55(8) defines substantially gainful employment as that which is ordinarily followed by the nondisabled to earn a livelihood, with earnings common to the particular occupation in the community where the veteran resides. Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). This suggests a living wage. Ferraro v. Derwinski, 1 Vet. App. 326, 332. "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16(a). The ability to work sporadically or obtain marginal employment is not substantially gainful employment, Moore v. Derwinski, 1 Vet. App. 356. 358 (1991). The question in a total rating case based upon individual unemployability due to service- connected disability is whether the veteran is capable of performing the physical and mental acts required by employment and not whether the veteran is, in fact, employed. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Assignment of a TDIU evaluation requires that the record reflect some factor that "takes the claimant's case outside the norm" of any other veteran rated at the same level. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15). Analysis Because the veteran's service-connected disabilities are each assigned only a 30 percent evaluation, the schedular criteria for assignment of a total disability rating based on individual unemployability are not met. 38 C.F.R. § 4.16(a). In this regard, the Board has carefully examined all of the evidence of record and finds that the veteran's current disability ratings are appropriately assigned, as set out in detail in the above reasons and bases pertinent to increased evaluations. Although the veteran has not met the percentage requirements set out in 38 C.F.R. § 4.16(a), a claim for a total disability rating based upon individual unemployability "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In this case, the Board has already determined that the veteran's right lower extremity disability does not warrant extraschedular consideration. The competent and probative evidence in this case is clear. First, despite his in- service injury, the veteran was able to maintain his job with the same employer for almost 18 years and the employer has reported only that he resigned. Moreover, although several physicians have indicated that the veteran has work impairment, no physician has opined that the veteran is unemployable solely by reason of his service-connected disabilities. To the contrary, the competent evidence of record indicates that the veteran additionally suffers from nonservice-connected peripheral neuropathy affecting his other extremities, to include affecting his ability to use his hands. The veteran himself, in connection with recent examination, gave the reason for leaving his employment as due to his inability to safely operate the required machinery, due, in part, to his hand problems. The record contains competent medical opinion attributing any unemployability to the combination of his service-connected and nonservice-connected disabilities. Although acknowledging that the veteran's PTSD worsened his ability to maintain employment, the recent psychiatrist has opined that with psychotherapy, the veteran may be able to function in employment. In sum, the available competent evidence does not show the veteran to be unemployable due solely to service-connected disabilities. Thus, the criteria for TDIU have not been met and the veteran's claim is denied. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (1999). ORDER An evaluation in excess of 30 percent for residuals of a shell fragment wound to the right lower extremity, with damage to the right femoral, is denied. An evaluation in excess of 30 percent for PTSD is denied. Entitlement to TDIU is denied. JANE E. SHARP Member, Board of Veterans' Appeals