Citation Nr: 18144624 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 16-28 921 DATE: October 24, 2018 ORDER Entitlement to a rating in excess of 10 percent for patellofemoral arthrosis, left knee is denied. Entitlement to a rating in excess of 10 percent for patellofemoral arthrosis, right knee with Baker’s cyst is denied. Entitlement to a rating in excess of 20 percent for mechanical low back pain with degenerative joint disease (DJD) is denied. REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for bilateral foot condition, to include as secondary to PTSD is remanded. Entitlement to a rating in excess of 70 percent for anxiety disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran’s bilateral knee disability has been manifested primarily by pain that required the use of braces and full flexion to 140 and extension to zero degrees. 2. The Veteran’s low back disability was manifested by flexion to 90 degrees without evidence of ankylosis or intervertebral disc syndrome (IVDS) with incapacitating episodes lasting at least four weeks or more. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for patellofemoral arthrosis, left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes (DC) 5099-5010, 5003, 5260, 5261. 2. The criteria for a rating in excess of 10 percent for patellofemoral arthrosis, right knee with Baker’s cyst have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5099-5010, 5003, 5260, 5261. 3. The criteria for a disability rating in excess of 20 percent for back disability have not been met. 38 U.S.C. §1155; 38 C.F.R. § 4.71a, DC 5237-5243 (formerly rated under DC 5010-5295). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1999 to November 2000. In March 2013, the Veteran filed an application for entitlement to service connection for finger condition, to include as due to PTSD and PTSD; entitlement to increased rating for anxiety disorder; and TDIU. In its February 2014 Notification letter, the Agency of Original Jurisdiction (AOJ) adjudicated all of the claims except for entitlement to service connection for finger condition. However, to date, it does not appear that any action has been taken regarding the Veteran’s finger condition. Therefore, the Board does not have jurisdiction over that claim and refers it to the AOJ for appropriate action, to include clarifying whether the Veteran is seeking service connection for a finger condition. 38 C.F.R. § 19.9(b). Increased Rating Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which allows for ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a Veteran’s condition. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a (General Formula, Note 1). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a rating in excess of 10 percent for patellofemoral arthritis, bilateral knee The Veteran is seeking a higher initial rating for her service-connected bilateral knee patellofemoral syndrome. In August 2001, the Veteran was initially awarded service connection for patellofemoral arthrosis, bilateral knees and assigned noncompensable ratings under DC 5010. In October 2012, the ratings were increased to 10 percent disabling based on painful motion. 38 C.F.R. § 4.59. The Veteran’s bilateral knee disability is currently rated under 5099-5010. When a particular disability is not listed among the diagnostic codes, a code ending in “99” is used; the first two numbers are selected from the portion of the schedule most approximating a Veteran’s symptoms. 38 C.F.R. § 4.27. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, DC 5099 refers to an unspecified musculoskeletal disorder and DC 5010 refers to arthritis due to trauma. Arthritis due to trauma under DC 5010 substantiated by x-ray findings is rated as degenerative arthritis under DC 5003. 38 C.F.R. § 4.71a, DC 5003. DC 5003 (arthritis, degenerative) provides that if degenerative arthritis is established by x-rays, then the disability is rated under the appropriate diagnostic code for the specific joint limitation of motion. When the rating of a specific joint is noncompensable under the codes pertaining to limitation of motion, a rating of 10 percent is for application for each major joint affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Diagnostic code 5260 is used to denote the rating criteria for the limitation of flexion of the leg. 38 C.F.R. § 4.71a. Limitation of flexion is rated as follows: flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. See 38 C.F.R. § 4.71a, DC 5260. Diagnostic Code 5261 evaluates limitation of extension as follows: extension limited to 5 degrees warrants a noncompensable rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. See 38 C.F.R. § 4.71a, DC 5261. Separate evaluations may be assigned for limitation of flexion and extension of the same joint. See VAOPGCPREC 09-04 (September 17, 2004). Specifically, when a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. The normal range of motion of the knee is 0 degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.7, Plate II. Analysis In February 2015, the Veteran was afforded a VA examination to determine the severity of her bilateral knee condition. The Veteran reported that she injured her right knee during basic training. The right patella dislocated, and it is estimated that the right patella has reportedly popped out about 24 times. Both knees started hurting since 1999. In 2012, she was found to have a medial meniscus tear of the left knee. She stated that the pain has become intermittent. The examiner confirmed the Veteran’s bilateral patellofemoral arthrosis and right knee meniscus tear and Baker’s cyst diagnoses. The Veteran reported flare-ups to include bilateral knee pain which occurred one hundred times per year. The flare-ups lasted one day or less and had a mild to moderate effect on the Veteran. The Veteran’s right and left knee forward flexion ended at 140 degrees or greater with painful motion beginning at 140 degrees. Bilateral extension ended at zero degrees with no evidence of painful motion. The Veteran was able to perform repetitive use testing. The Veteran did not have additional limitation in range of motion (ROM) of the knee and lower leg following repetitive-use testing. She experienced functional loss and/or functional impairment of the knee and lower leg, to include bilateral pain on movement, bilateral sub-patellar crepitus on flexion/extension, and tender right Baker’s cyst. Pain, weakness, fatigability, or incoordination did not significantly limit her functional ability during flare-ups, or when the joint was used repeatedly over a period of time. She experienced right knee tenderness or pain to palpation for joint line or soft tissues. Her muscle strength and joint instability tests were normal. There was no evidence or history of recurrent patellar subluxation/dislocation. She did not now have or has ever had “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran had right knee meniscus (semilunar cartilage) condition. She experienced meniscal tear and frequent episodes of joint locking and joint pain. She did not have a meniscectomy or residual signs and/or symptoms due to a meniscectomy. The Veteran did not have joint replacement or other surgical procedures. She did not have any scars (surgical or otherwise) related to her bilateral knee conditions. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the Veteran’s bilateral knee conditions. She used braces as a regular means of locomotion. Her functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The Veteran’s knee had an impact on her ability to work. She avoided deep squats or kneeling. She was limited to walking two to three miles at one time. During an eight-hour day, she was able to walk an unlimited amount of time; however, she had to take breaks every 30 minutes. She was able to sit for an unlimited amount at one time but was able to stand for 20 to 40 minutes. During an eight-hour day, she was able to sit or stand for eight hours but with breaks every 20 to 40 minutes. The Veteran’s VA treatment records document complaints of bilateral knee pain. Given that the record shows bilateral knee flexion to no less than 140 degrees, the criteria for a disability rating higher than 10 percent under DC 5260 is not met. The Board recognizes that, under DeLuca v. Brown, 8 Vet. App. 202 (1995), VA must consider “functional loss” of a musculoskeletal disability separately from consideration under the diagnostic codes. “Functional loss” may occur because of weakness or pain on motion. Here, the evidence shows that pain has been a constant and predominant symptom. The Veteran also experienced bilateral sub-patellar crepitus on flexion/extension and tender right knee Baker’s cyst. However, the Board finds that given the extent of bilateral knee motion and the extent of functional and occupational impairment indicated in the record, the evidence does not support a disability picture that establishes entitlement to a higher disability rating, even after taking her reported pain into full consideration. See DeLuca, 8 Vet. App. at 204 -07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5260 and 5261. In this regard, the Board emphasizes that a 10 percent disability rating under DC 5260 already contemplates an otherwise non-compensable degree of limitation of motion verified by objective evidence of symptoms such as painful motion. The Board also notes that the Veteran has normal extension; therefore, a separate rating under 5261 is not warranted. Further, the Board has considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board notes that other criteria for rating knee disabilities are provided under DCs 5256 (for ankylosis), and 5262 (for impairment of the tibia and fibula). The evidence does not show that the Veteran’s bilateral knee disability manifestations have included ankylosis or impairment of the tibia and fibula. In the absence of such manifestations, those DCs are inapplicable in this case. The VA examiner noted that the Veteran had right knee meniscus tear with frequent episodes of joint locking and joint pain. However, she did not experience effusion into the joint. Therefore, a separate rating is not warranted under DC 5258 (for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion). Additionally, 5259 (for symptomatic removal of the semilunar cartilage) is inapplicable in this case. The Board acknowledges that in Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) noted the final sentence of § 4.59, which states “[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.” In this case, there is no indication of whether Veteran was not tested for both active and passive motion and in weight-bearing and non-weight bearing. However, the Board finds that the February 2015 examination report adequately document the Veteran’s symptoms as they relate to the rating criteria. Additionally, the examiner, addressing range of motion in any capacity, noted full range of motion for the knees. Therefore, while it appears that passive range of motion and nonweight-bearing were not tested, it is reasonable to assume that range of motion would be less limiting than active motion and weight bearing, and therefore, the failure to measure passive motion and nonweight bearing is harmless error. See Correia v. McDonald, 28 Vet. App. 158, 170 (2016). The Board has considered the Veteran and her representative’s statements regarding the severity of the Veteran’s bilateral knee conditions. However, as lay persons, the Veteran and her representative do not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiner’s findings. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s disability picture more nearly approximates a rating in excess of 10 percent. 2. Entitlement to a rating in excess of 20 percent for mechanical low back pain with DJD In August 2001, the Veteran was awarded service connection for mechanical low back pain and assigned a 10 percent rating under DC 5295 for painful or limited motion. In October 2012, the rating was increased to 20 percent for guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Veteran’s disability is currently rated under DC 5010-5295. Diagnostic Code 5295 (prior to September 26, 2003), provides a 10 percent evaluation is warranted for lumbosacral strain with characteristic pain on motion. A 20 percent evaluation is warranted for lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position. Lastly, a 40 percent disability evaluation is warranted for severe lumbosacral strain with listing of the whole spine to the opposite side, positive Goldthwait’s sign, marked limitation of forward bending in standing position, loss of lateral lumbar motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a, DC 5295. Since September 26, 2003, limitation of motion of the spine is rated under 38 C.F.R. § 4.71a, DCs 5235-5243 according to a General Rating Formula for Disease and Injuries of the Spine (General Formula) unless DC 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on incapacitating episodes (IVDS Formula). For purposes of evaluations under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed and treatment by a physician. Schedular disability ratings are assigned for the spine from 100 percent to 10 percent according to the formulas as follows: Under the General Formula, a 20 percent rating contemplates forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Under the General Formula, a 40 percent rating contemplates forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Alternatively, under the IVDS Formula, a 40 percent rating contemplates incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Under the General Formula, a 50 percent rating contemplates unfavorable ankylosis of the entire thoracolumbar spine. There is no equivalent rating under the IVDS Formula. Under the IVDS Formula, a 60 percent rating contemplates incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. There is no equivalent rating under the General Formula. Under the General Formula, a 100 percent rating contemplates unfavorable ankylosis of the entire spine. There is no equivalent rating under the IVDS Formula. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003 (degenerative arthritis). However, when there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. A rating of 20 percent requires x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Analysis The Veteran contends that her mechanical back condition is worse than the 20 percent rating depicts. In February 2015, the Veteran was afforded a VA examination to determine the severity of her back condition. The Veteran stated that during basic training she rolled down an embankment and struck the side of a vehicle with immediate onset of back pain. The back pain has persisted and now occurs daily. The examiner confirmed the Veteran’s lumbosacral strain of recurrent nature with mechanical low back pain and thoracolumbar DJD diagnoses. The Veteran reported between 25 to 50 flare-ups per year. The flare-ups lasted one to a few hours and had a mild to moderate effect on the Veteran. The Veteran’s forward flexion was to 90 degrees or greater with objective evidence of painful motion beginning at 35 degrees. Extension was to 30 degrees with objective evidence of painful motion beginning at 15 degrees. Right lateral flexion and right and left lateral rotation were to 30 degrees with no objective evidence of painful motion. Left lateral flexion was to 30 degrees with objective evidence of pain beginning at 25 degrees. The Veteran was able to perform repetitive-use testing with three repetitions. She did not experience additional limitation in ROM of the thoracolumbar spine (back) following repetitive-use testing. However, there was additional functional loss and/or functional impairment to include pain on movement. The Veteran’s pain could significantly limit functional ability during flare-ups, or when the joint was used repeatedly over a period of time. The examiner was unable to describe additional ROM loss due to “pain on use or during flare-ups” because the Veteran was unable to replicate the estimated limitation at the time of examination. The Veteran experienced localized tenderness or pain to palpation in the bilateral lumbar region. She did not have guarding or muscle spasm of the thoracolumbar spine. The Veteran had normal muscle strength with no muscle atrophy. Her reflex and sensory exams were normal. Straight leg testing was negative. The Veteran did not have pain or any other signs or symptoms of radiculopathy. She did not experience any neurological abnormalities or findings related to her condition such as bowel or bladder problems; IVDS and incapacitating episodes; scars; or any other pertinent physical findings, complications, conditions, signs or symptoms due to her back disability. The Veteran wore a brace on her right knee on a regular basis. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Imaging revealed arthritis but no vertebral fracture. There were no other significant diagnostic test findings and/or results. The Veteran’s disability had an impact on her ability to work. She was able to walk, sit, and/or stand for unlimited amounts of time. However, because of her back, she avoided repetitive lifting or stooping. Additionally, she was limited to lifting 65 pounds. In June 2017, the Veteran was seen for her low back condition. She complained of back pain. There were no deformities and straight leg testing was negative. She had good flexibility and range of motion was normal. The Board finds that a disability rating in excess of 20 percent is not warranted. Diagnostic Code 5242 provides ratings in excess of 40 percent where there is limitation of forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. However, the Veteran’s flexion was 90 degrees with functional loss considered. There was no evidence of ankylosis or IVDS with incapacitating episodes. Therefore, a rating in excess of 20 percent under DC 5242 is not warranted. The Board has also considered the effect of pain and weakness in evaluating the Veteran’s disability. 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, 8 Vet. App. 202 (1995). The Board notes that the Veteran had some functional loss/impairment which resulted in pain on movement. Although the Veteran experienced additional functional limitation, the loss in range of motion is not commensurate with that for the next higher rating. Based on the evidence, the Board finds that the current 20 percent evaluation adequately portrays any functional impairment, pain, and limitation of motion that the Veteran experienced due to his back disability. See DeLuca, 8 Vet. App. 202; 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran has a current diagnosis of lumbar spine DDD, as confirmed by x-ray imaging. However, the Veteran’s lumbar spine disability is already rated at 20 percent disabling. Therefore, no additional higher or alternative ratings under DC 5003 can be applied. Finally, the Board has considered whether separate ratings are warranted for other neurologic abnormalities. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). However, the evidence does not show any objective neurologic abnormalities associated with the Veteran’s lumbar spine disability. With respect to conducting a rating examination relative to joint dysfunction, the Court held that a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59 which are tests as to pain on active and passive motion, including weight-bearing and nonweight-bearing and, if possible, with range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168-70. In this case, the relevant VA rating examinations did test for pain on motion. As to weight-bearing, it must be noted that all tests of spinal motion are done while in a weight-bearing status inasmuch as the only means of testing nonweight-bearing is if the examined is either supine or prone, in which case testing of range of motion in all planes is simply not possible. Similarly, the spine is a single group of joints and, as such, there is no opposite joint, much less an undamaged opposite joint. Thus, the holding in Correia is not applicable. The Board has considered the Veteran and her representative’s statements regarding the severity of the Veteran’s back disability. However, as lay persons, the Veteran and her representative do not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiner’s findings. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s disability picture more nearly approximates a rating in excess of 20 percent. REASONS FOR REMAND Regarding the Veteran’s anxiety disorder, the Board notes that since the May 2016 Statement of the Case (SOC), new and relevant evidence has been added to the record, namely a September 2018 VA examination. As such, the Board must remand this matter so that the agency of Original Jurisdiction (AOJ) can consider the report in the first instance. The Veteran has been diagnosed with PTSD. The Veteran contends that her PTSD is due to military sexual trauma she experienced in service. The Board notes that she has not been afforded a VA examination to determine the nature and etiology of her claimed disability. As such, a VA examination is necessary to determine if the Veteran’s PTSD is related to her military service. Additionally, the Veteran has also been diagnosed with bilateral pes planus and mild arthritis in her right foot. The Veteran contends that her foot condition is related to military service or in the alternative, secondary to her PTSD. Therefore, the Board finds that this claim is inextricably intertwined with her pending service connection claim for PTSD. Thus, it is appropriate to defer final appellate review until the inextricably intertwined claim has been adjudicated. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). The Board notes that the claim for TDIU is “inextricably intertwined” with the claims on appeal, so it must be remanded. Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain and associate all outstanding VA treatment records with the claims file. 2. Contact the Veteran and request that she identify all private providers who have treated her for her psychiatric disorders. After obtaining authorization, obtain all outstanding, non-duplicative records. If the records are unavailable, document the claims file and notify the Veteran in accordance with 38 C.F.R. § 3.159(e). 3. Schedule a VA examination to determine the nature and etiology of the Veteran’s PTSD. The complete record, to include a copy of this remand and the claims folder, must be made available to and reviewed by the examiner in conjunction with the examination. The examination report must include a notation that this record review took place. If PTSD is diagnosed, the examiner should opine as to whether it is at least as likely as not (a 50 percent or better probability) that such disability is related to the Veteran’s service, to include her reported stressor? 4. After completing the aforementioned and any further development deemed necessary considering the expanded record, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, furnish the Veteran and her representative with an SSOC and allow them an opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD