Citation Nr: 1040482 Decision Date: 10/28/10 Archive Date: 11/04/10 DOCKET NO. 06-37 423 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 30 percent for a left hip disability (status post Jewett's nail pinning, fractured left femur with pain, left hip, thigh and knee). 3. Entitlement to a rating in excess of 10 percent for a right great toe disability (status post hallux limitus). 4. Entitlement to a compensable rating for residuals of a stress fracture of the right second metatarsal. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Ms. LS ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from September 1981 to April 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued in December 2005 and October 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The Veteran testified before the RO's Decision Review Officer (DRO) in a hearing in March 2008. A transcript of that testimony is associated with the claims file. The Veteran was scheduled to testify before a Member of the Board in a hearing at the RO in May 2010, but before the hearing she notified the RO in writing that she wanted her hearing to be cancelled and requested the Board to consider her claims based on the existing record. She also submitted new documents, with a waiver of initial RO jurisdiction; the Board has accepted this additional evidence for inclusion into the record on appeal. See 38 C.F.R. § 20.800. The Veteran's claims for service connection for an acquired psychiatric disorder and entitlement to a TDIU are addressed in the Remand that follows the Order section below. FINDINGS OF FACT 1. The Veteran's disability of the left hip and leg is manifested by marked hip disability with pain, but not by nonunion of the femur or by false joint. 2. The Veteran's disabilities of the right great toe and right second metatarsal are currently compensated at the disability rating applicable for elective amputation of those appendages. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for a left hip and left leg disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5255 (2009). 2. The criteria for a rating in excess of 10 percent for a right great toe disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.68, 4.71a, Diagnostic Codes 5003, 5171, 5284 (2009). 3. The criteria for a compensable rating for right second metatarsal disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.68, 4.71a, Diagnostic Codes 5172, 5282 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran asserts entitlement to higher evaluations for her service-connected disabilities of the left hip and leg, right great toe and right second metatarsal. The Board will initially discuss certain preliminary matters and will then address the pertinent law and regulations and their application to the facts and evidence. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2009), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2009), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The record reflects that the Veteran was provided all required notice in a letter mailed in February 2007, prior to the October 2007 rating decision on appeal. In addition she was sent a letter in June 2008 advising her of the disability-rating and effective-date elements, as well elements required to support a claim for increased evaluation for her service-connected disability and of the respective duties of VA and the claimant in obtaining supporting evidence. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The Federal Circuit Court recently vacated the Court's previous decision in Vazquez-Flores, concluding that generic notice in response to a claim for an increased rating is all that is required. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). Regardless, overall, the Board is satisfied that the RO provided both generic and specific VCAA notice as to the increased rating claim when considering all of the VCAA letters provided. The Board also finds VA has complied with its duty to assist the Veteran in the development of her claims. In this regard, the Board notes that service treatment records (STRs) and service personnel records (SPRs) have been obtained, as well as post- service treatment records from VA and private medical providers. In addition the Veteran was provided appropriate VA examinations addressing the periods of the claims decided herein. Neither the Veteran nor her representative has identified any outstanding evidence that could be obtained to substantiate either claim. The Board is also unaware of any such evidence. In sum, the Board is satisfied that any procedural errors in the development and consideration of the claims by the originating agency were insignificant and not prejudicial to the Veteran. Accordingly, the Board will address the merits of the claims. General Legal Principles Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2009). The percentage ratings contained in the Rating 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 their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2009). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where a particular disability for which the veteran has been service-connected is not listed, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical area and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more of less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2009) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service- connected disabilities on appeal. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of remote clinical histories and findings pertaining to the disabilities. The Veteran's instant claim for increased rating was received in October 2006. The Board has considered evidence of symptoms since October 2005, one year prior to receipt of the claim for increase. Evaluation of Left Hip and Leg Disability Fracture of the femur is rated under the criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5255 (impairment of the femur), as follows. A rating of 30 percent is assigned for malunion with marked knee or hip disability. A rating of 60 percent is assigned for fracture of the surgical neck with false joint, or for fracture of the shaft or the anatomical neck with nonunion but without loose motion and with weight bearing preserved with aid of a brace. A rating of 80 percent is assigned for fracture of the shaft or anatomical neck with nonunion with loose motion (spiral or oblique fracture). Alternatively, rating in excess of 30 percent may be warranted with flail joint of the hip (80 percent under Diagnostic Code 5254), or for limitation of flexion of the thigh to 10 degrees (40 percent under Diagnostic Code 5252). Impairment of the thigh in terms of limitation of abduction, adduction or rotation is rated under the criteria of Diagnostic Code 5253, but that diagnostic code does not provide for a rating higher than 20 percent and would thus not be favorable to the Veteran. Rating higher than 30 percent may be warranted under Diagnostic Code 5250 for ankylosis of the hip, but the Veteran's left hip is not ankylosed so that diagnostic code is not applicable. The Board notes at the outset that the Veteran is separately compensated for surgical scar associated with the left hip fracture. The rating for her scar is not on appeal before the Board and the scar will not be considered below. The Veteran had a VA joints examination in October 2005 in which she complained of constant hip pain of 5/5 severity, sometimes increasing to 7/8 severity. Treatment consistent of pain medication four times per day, physical therapy, transcutaneous electrical nerve stimulation (TENS) therapy, heat application and pillow between the knees at night. She endorsed using orthotic shoe inserts, corrective shoes and a cane. She asserted she could stand for 15-30 minutes and walk one-quarter mile. The Veteran was observed to walk with antalgic gait; although a weight-bearing joint was affected there was no evidence of abnormal weight bearing. Flexion was 0 to 120 degrees, with pain beginning at 115 degrees. On repetitive use, flexion was reduced to 110 degrees due to pain. The left leg was 1 cm. shorter than the right leg. There was painful motion, tenderness and guarding of the left hip. X-ray showed screw track in the left proximal femur related to previous hardware placement but no significant hip joint degenerative joint disease (DJD), fracture or dislocation. In regard to activities of daily living (ADLs) the examiner opined that the left hip disorder would have severe effect on chores, shopping, exercise, sports, recreation and traveling; mild effect on bathing, dressing, toileting and grooming; and, no effect on feeding. In November 2006 the Veteran presented to her VA physician complaining of increase in her chronic left leg pain during the last few months. The pain appeared to be neuropathic. The physician discussed various pain medication options. The Veteran submitted a letter to VA in February 2007 asserting that because of her left hip and right foot disabilities she was unable to drive for any length of time. A February 2007 letter from Colleen Jensen states on the basis of an 8-year close friendship that the Veteran's left hip disability caused her to suffer tremendously standing, sitting and sleeping; she occasionally needs the help of a cane to be able to stand. A February 2007 letter from Denise Guenette states she had been a good friend of the Veteran for 20 years, and she observed the Veteran's broken leg and foot had changed her life. The Veteran could not maintain employment due to her need to lie down often. A February 2007 letter from VA physician Mark Gilbert states the Veteran had been struggling for many years with left leg pain. She had consultations with neurology, orthopedics, psychiatry, podiatry and pain management. She gradually had to decrease activities and was no unable to work due to the pain and disability, and was now on regular doses of prescription pain medication. The Veteran had a VA examination of the joints in March 2007. The examiner reviewed the claims file and treatment records. The Veteran subjectively complained of pain with prolonged sitting as well as any movement or ambulation. She claimed to have excruciating pain even at rest, continuously at 8/10 level and increasing to 10/10 or 15/10 level; pain medications provided minimal relief. She stated that pain made her family and social life very stressful and that she felt herself to be a burden to her family. She also asserted she was unemployable because of her pain. As in the previous examination she endorsed using orthotic soles, corrective footwear and a cane. She stated she could stand for 15-30 minutes at a time but could walk only a few yards. On examination the Veteran evinced pain and guarding with all movements and was observed to limp to the left; she was unable to squat, duck walk or heel-and-toe walk. Her range of flexion was 0 to 90 degrees, with pain beginning at 70 degrees; with repetition flexion decreased to 60 degrees due to pain/fatigue/lack of endurance. The left leg was 1 cm. shorter than the right leg. The examiner noted the Veteran's range of motion testing was markedly decreased when compared to the examination in October 2005, perhaps because the present examination was being performed during a reported period of flare-up. X-ray showed no changes since the study in October 2005; i.e., no evidence of degenerative change in the hip. The examiner summarized the Veteran's problem as left leg and left hip pain secondary to post-traumatic arthritis and post- surgical residuals with continued muscle sprain/strain from discrepancy in her bilateral leg length and alteration in the musculoskeletal biomechanics and hip kinematics. The examiner stated the disorder had no effect on feeding but severe effect on all other ADLs (chores, shopping, exercise, sports, recreation, traveling, bathing, dressing, toileting and grooming). In regard to employment, the examiner stated the right foot and left leg and hip symptoms could definitely be impairing or impacting the Veteran's physical ability for meaningful employment needing ambulation or prolonged sitting down; sedentary employment seemed to be limited more by psychiatric issues including PTSD and depression related to chronic pain. In March 2008 the Veteran testified before the RO's DRO that her hip pain and weakness sometimes confines her to the couch or to her bed; she is able to rise only for brief periods. The Veteran's husband submitted a letter in March 2010 that asserts the Veteran spend most of her day lying down due to spasms in her leg; he had to assist her running errands and for years she was unable to leave the house to shop for groceries. The Veteran had been unable to work full-time for many years; she was most recently employed as a certified health care aide for elderly women but she had to give up that position because she was informed that she would have to work full-time as a condition of keeping her certification. On review of the evidence above the Board acknowledges the Veteran has a severe disorder of the left hip and leg, as documented in her medical records and lay evidence. However, there is no schedular basis for rating higher than the currently assigned 30 percent. First, the Veteran does not have fracture of the surgical neck with false joint or nonunion of the hip, which are threshold criteria for rating higher than 30 percent under Diagnostic Code 5255. Second, the Veteran's flexion of the left leg, even after allowing for pain and repetitive motion, was to 110 degrees in October 2005 and to 60 degrees in March 2007. Under Diagnostic Code 5252, flexion in excess of 45 degrees is not compensable, and rating in excess of the currently-assigned 30 percent requires limitation of flexion to 10 degrees. Thus, application of Diagnostic Code 5252 does not benefit the Veteran. VA must consider the effect of pain and weakness when rating a service-connected disability on the basis of limitation of range of motion. DeLuca v. Brown, 8 Vet. App. 202 (1995), discussing 38 C.F.R. §§ 4.40 and 4.45. However, the Veteran was able to achieve motion within the noncompensable range despite pain, fatigability, weakness or incoordination, so application of DeLuca does not show entitlement to higher rating for increased limitation of function. Third, the Veteran is not shown to have flail joint, which would entitle her to higher compensation under Diagnostic Code 5254, or ankylosis, which would entitle her to higher rating under Diagnostic Code 5250. She has not had a hip replacement, which would enable the disability to be rated under the criteria of Diagnostic Code 5054. The Board notes that the Veteran's left leg is shorter than the right leg by 1 cm. Shortened bones in the lower extremity are compensated under Diagnostic Code 5275, but compensable rating (10 percent) begins with shortening of at least 3.2 cm. In sum, the disability picture presented by the Veteran's left hip disorder does not approximate the criteria for higher rating under any applicable diagnostic code. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly considered the lay evidence offered by the Veteran, in the form of correspondence to VA and her testimony before the DRO, in addition to the medical evidence cited above. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Similarly, her husband and her acquaintances can certainly provide an eyewitness account of the Veteran's visible symptoms. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, even affording the Veteran and her family and friends full competence and credibility, their evidence simply does not show entitlement to higher rating under any applicable diagnostic code. Based on the evidence and analysis above the Board finds the criteria for a rating higher than 30 percent are not met. Accordingly, the claim must be denied. Evaluation of Right Foot Disorders The RO has rated the Veteran's right great toe disability under the criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5284 (other disorders of the foot) and has rated the disability of the second metatarsal under the criteria of Diagnostic Code 5282 (hammer toes). The record reflects that hallux limitus, the underlying right great toe disability, is a trauma-induced arthritic disorder of the first metatarsophangeal joint. See letter dated in July 1999 by VA podiatrist Dr. James Kerr. Degenerative arthritis established by X-ray findings will rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, because there is no diagnostic code for limitation of motion of the toes, and the Veteran's great toe disability has been rated under the criteria of Diagnostic Code 5284 (other foot disorders). Under Diagnostic Code 5282 (hammer toes), unilateral disorder without claw foot of all toes is rated as 10 percent disabling; disorder of a single toe is noncompensable. Under Diagnostic Code 5284 (other foot disorders), a 10 percent rating is warranted for a moderate disability, a 20 percent rating is warranted for moderately severe disability and 30 percent rating is warranted for severe disability. With actual loss of the foot, rate at 40 percent. The terms "moderate," "moderately severe" and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Under the "amputation rule" the combined rating for disabilities of an extremity may not exceed the rating for the amputation at the elective level, were the amputation to be performed. 38 C.F.R. § 4.68. In this case, per Diagnostic Code 5151, amputation of the great toe is compensable at 10 percent without metatarsal involvement, and at 30 percent with metatarsal involvement. Per Diagnostic Code 5172, amputation of any other toe without removal of the metatarsal head is not compensable. The Veteran submitted a letter to VA in February 2007 asserting that because of her left hip and right foot disabilities she was unable to drive for any length of time. The Veteran had a VA examination of the feet in March 2007. The examiner reviewed the claims file and treatment records. The Veteran reported excruciating right foot pain, continuously 7/10 and increasing to 8/10 or 9/10, minimally relieved by medication. The Veteran endorsed wearing orthotic soles, corrective shoes and constantly relying on a cane. She reported pain, stiffness and weakness standing, walking and while at rest. She reported flare-ups weekly or more often, lasting 1-2 days and associated with any movement. She stated she was unable to stand more than a few minutes or walk more than a few yards. On examination the right great toe was painful with dorsiflexion and had limited motion to 10 degrees. There was tenderness over the first and second metatarsals with weakness but no instability. There was abnormal weight-bearing as evidenced by shoe wear and antalgic gait. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones. There was a scar on the right great toe measuring up to 6 cm. with moderate tenderness (well-healed with no induration) secondary to left great toe operation in 1995 after active service. X-ray of the right foot showed minimal hallux valgus deformity, moderately severe degenerative changes in the first metatarsophalangeal joint with narrowed joint space, no current fractures and otherwise unremarkable. The examiner characterized the disability as right forefoot pain and metatarsalgia secondary to posttraumatic arthritis secondary to previous stress fracture and post-surgical residuals while on active duty. As noted above in relation to evaluation of the left hip disability, the examiner stated the Veteran's right foot and left leg and hip symptoms could definitely be impairing or impacting her physical ability for meaningful employment needing ambulation or prolonged sitting down; sedentary employment seemed to be limited more by psychiatric issues including PTSD and depression related to chronic pain. In terms of ADLs the examiner stated the disability has mild effect on feeding; severe effect on chores, bathing, dressing, toileting, grooming, and driving; and, prevents shopping, exercise, recreation and traveling. A December 2008 letter from Dr. Kerr states the Veteran was being followed by the VA podiatry clinic for chronic painful feet secondary to bilateral hallux limitus deformity. Despite surgical attempts at correction she continued to have pain and disability. Her condition was complicated by chronic leg and hip pain that caused an antalgic gait, which severely limited her ability to walk or stand. She was no longer able to work because of these conditions. On review of the evidence above, the Board finds the "amputation rule" applies to the great toe. Although Diagnostic Code 5284 provides for higher ratings for moderately severe or severe disability of the entire foot, the Veteran's great toe disability cannot be rated higher than 10 percent, the rating appropriate for amputation of that joint without metatarsal involvement. Rating of 30 percent under the amputation rule for amputation with metatarsal involvement is not applicable in this case because VA X-ray showed no malunion or nonunion of the metatarsal bones. The Board notes that X-ray confirmed moderately severe degenerative disease of the first metatarsophalangeal joint. Painful motion of a major joint or groups caused by degenerative arthritis, where the arthritis is established by X-ray, is deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even though there is no actual limitation of motion; see VAOPGCPREC 09-98 (August 14, 1998), citing Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Although the great toe is not a "major joint" the VA examiner has described impairment in gait that affects the entire foot and thus approximates a major joint. Thus, Lichtenfels applies, but the Veteran's currently-assigned 10 percent rating for the great toe satisfies the requirement therein. In regard to the disability of the second metatarsal, the "amputation rule" makes disabilities of that toe noncompensable. Further, there is no indication on X-ray of any current fracture or other disorder of the second toe. Thus, while service connection has been essentially granted for residuals of a stress fracture to the second metatarsal during service, there is no clinical evidence of any current residuals of such fracture other than subjective tenderness to palpation, which is not compensable under the amputation rule. The Board has considered the lay evidence offered by the Veteran, but finds nothing therein to justify an award in excess of that allowed under the amputation rule. Based on the evidence and analysis above the Board finds the criteria for a rating higher than 10 percent for right great toe disability and compensable rating for right second metatarsal disability are not met. Accordingly, the claims must be denied. Extraschedular Evaluation The Board has considered whether referral for extraschedular evaluation is warranted for the service-connected left hip and right foot disabilities on appeal. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed.Cir. 2009). The first question is whether the schedular rating adequately contemplates the veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Here, the Board finds that the record reflects that the Veteran has not required frequent periods of hospitalization for her disabilities on appeal, and that the manifestations of those disabilities are contemplated by the schedular criteria. Therefore, there is no reason to believe that the average industrial impairment from the disabilities would be in excess of that contemplated by the schedular criteria, and referral of the case for extra- schedular consideration is not in order. ORDER Evaluation in excess of 30 percent for a left hip and leg disability is denied. Evaluation in excess of 10 percent for a right great toe disability is denied. Compensable evaluation for stress fracture of the second metatarsal is denied. REMAND The Board finds that further development is required before the claims for service connection for an acquired psychiatric disorder and for entitlement to a TDIU can be adjudicated. In regard to the claim for service connection for a psychiatric disorder, the Veteran asserts she has PTSD due to military sexual trauma (MST). When the claimed PTSD stressor is physical or sexual assault in service, credible supporting evidence may consist of a medical opinion, based on review of the evidence, that the personal assault occurred. 38 C.F.R. § 3.304(f)(4) (emphasis added). In this case, the file includes opinion by a VA social worker, endorsed by a VA psychiatrist, that the Veteran has PTSD due to MST, as well as another VA psychiatrist's diagnosis of PTSD/MST. Those providers did not review the record, so their opinion does not constitute adequate stressor verification under the criteria of 38 C.F.R. § 3.304(f)(4). However, their opinions cannot be ignored, and further development is warranted. Under 38 C.F.R. § 3.304(f)(4), VA may submit evidence to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. The Board finds that, as the Veteran has not yet received a VA psychiatric examination in conjunction with her claim for service connection, she should be afforded an examination at this point to determine whether the cited assault occurred, and whether she has PTSD or any other current psychiatric disorder that was incurred in or aggravated by active service. The October 2007 rating decision on appeal denied entitlement to a TDIU because the Veteran did not meet the schedular threshold requirement. Resolution of her claim for service connection for an acquired psychiatric disorder, if favorable, could raise the Veteran to the requisite schedular level for consideration, so adjudication of the TDIU claim is deferred until the service connection claim is resolved. The Board also notes that the February 2007 notice letter erroneously informed the Veteran that she had to submit new and material evidence in support of her claim for a TDIU; she was not advised therein or thereafter of the elements required to show entitlement to a TDIU. A TDIU claim is, in essence, a claim for an increased rating; Norris v. West, 12 Vet. App. 413, 420 (1999). There is accordingly no need for the Veteran to provide new and material evidence. The AOJ should therefore provide the Veteran with corrective notice, to include the elements required to establish entitlement to a TDIU and extraschedular consideration under 38 C.F.R. § 4.16(b), and provide her an appropriate opportunity to respond before the claim is readjudicated. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The Veteran should be provided with notice of the evidence required to establish entitlement to a TDIU, to include extraschedular compensation under 38 C.F.R. § 4.16(b), and of the respective duties of VA and the claimant in obtaining such evidence. The Veteran should thereafter be provided appropriate time in which to respond. 2. The Veteran also should be afforded an examination by a psychiatrist or psychologist to determine the diagnosis and etiology any acquired psychiatric disorder. The claims folders must be made available to and reviewed by the examiner, and any indicated studies should be performed. Based on review of the files and examination of the Veteran, the examiner should state a medical opinion as to whether the Veteran experienced traumatic personal or sexual assault during active service, and if so whether she currently has PTSD or other acquired psychiatric disorder resulting from such trauma. If the Veteran has any acquired psychiatric disorder other than PTSD, the examiner should state an opinion as to whether such disorder originated in active service or is due to active service. The rationale for each opinion expressed must also be provided. 3. The RO or the AMC should also undertake any other development it determines to be warranted. 4. Then, the RO or the AMC should readjudicate the issues of service connection for an acquired psychiatric disorder and entitlement to a TDIU. If the Veteran does not meet the schedular threshold for TDIU under 38 C.F.R. § 4.16(a) the RO or AMC should discuss whether extraschedular consideration under 38 C.F.R. § 4.16(b) is warranted. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the RO or the AMC should furnish to the Veteran and her representative a supplemental statement of the case and afford them the requisite opportunity to respond. Thereafter, if indicated, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until she is otherwise notified, but she may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ J.W. FRANCIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs