Citation Nr: 1808860 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 14-01 681 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for hypertension. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for bilateral pes planus. 4. Entitlement to service connection for bilateral plantar fasciitis. 5. Entitlement to service connection for a right knee disorder, to include as secondary to the service connected left knee disorder. 6. Entitlement to service connection for a psychiatric disorder, to include bipolar disorder and generalized anxiety disorder. 7. Entitlement to service connection for a gynecological disorder, to include endometriosis. 8. Entitlement to a rating higher than 30 percent for Crohn's disease with diverticulitis and gastroesophageal reflux disease (GERD). 9. Entitlement to a compensable rating for left knee patellofemoral syndrome. 10. Entitlement to a total disability rating based on individual unemployability due to the service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran had active duty in the Navy-Navy Reserves (USNR) from October 2002 to September 2003, and from October 2003 to February 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from August 2013, October 2014, March 2015, and May 2016 rating decisions issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In July 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board video conference hearing. A transcript of that hearing is associated with the claims file. Relevant to the Veteran's claim for service connection for a psychiatric disorder, the claim has not been certified to the Board, although following a timely notice of disagreement and a February 2016 statement of the case, the appeal was perfected for appellate review in April 2016. See 38 C.F.R. § 20.200. In light of this, the fact that the undersigned took hearing testimony on this issue in July 2017, and as the issue is being remanded for additional development, the Board finds that there is no bar to taking jurisdiction over these issues at this time. Additionally, the Board notes that a claim for service connection for a psychiatric disability is deemed to encompass all psychiatric diagnoses reasonably presented in the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Pursuant to Clemons, the Board has expanded the service connection claim as reflected on the title page of this decision. The Board also notes that additional evidence has been received since the last adjudication of the claims by the Agency of Original Jurisdiction (AOJ). The additional evidence is either not relevant to the claims herein decided or is cumulative of evidence already on file when the claims were last readjudicated. Therefore, a waiver of AOJ review is not required for these claims. Moreover, regarding the claims being remanded, there is no prejudice to the Veteran, as the Agency of Original Jurisdiction (AOJ) will have an opportunity to review this evidence on remand. See 38 C.F.R. § 20.1304 (c) (2016). The claim for entitlement to service connection for hypertension, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In a rating decision in May 2010, the RO declined to reopen the claim for service connection for hypertension, the Veteran did not appeal that decision and it became final. 2. The evidence received since the May 2010 rating decision is not cumulative or redundant of evidence previously of record and relates to unestablished facts necessary to substantiate the claim for service connection for hypertension. 3. The preponderance of the evidence is against a finding that bilateral pes planus, noted on enlistment examination, underwent an increase in severity during service. 4. The most probative evidence indicates that bilateral plantar fasciitis was not shown in service or for many years thereafter; plantar fasciitis was not incurred in service, is not otherwise related to service and was not caused by a service-connected disability. CONCLUSIONS OF LAW 1. The May 2010 rating decision that declined to reopen the Veteran's claim for service connection for hypertension disorder is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 2. New and material evidence has been received, and the claim for service connection for hypertension is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1110, 1111, 1153, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2017). 4. The criteria for service connection for bilateral plantar fasciitis have not been met. 38 U.S.C. §§ 1110, 1111, 1153, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the Veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). New and Material Evidence Generally, if a claim for service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108 (2012). "New" evidence is defined as existing evidence not previously submitted to agency decisionmakers. "Material" evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative, nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Despite the determination reached by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). In the context of reserve component service, the term "active military, naval or air service" includes any period of active duty for training in which the individual was disabled from a disease or injury and any period of inactive duty training during which the individual was disabled from an injury, if that injury was incurred or aggravated in the line of duty. 38 U.S.C. § 101 (24). Active duty for training (ACDUTRA) is defined as full-time duty in the Armed Forces performed by Reserves for training purposes. 38 U.S.C. § 101 (22). Inactive duty for training (INACDUTRA) is defined as other than full-time duty performed by the Reserves. 38 U.S.C. § 101 (23). The Veteran's claim for service connection for hypertension was originally denied in February 2005, on the basis that hypertension existed prior to service and there was no evidence that the condition permanently worsened as a result of service. The Veteran was informed of the decision and of her appellate rights, but she did not appeal that decision. Thereafter, in a rating decision in May 2010, the RO declined to reopen the claim for service connection for hypertension because new and material evidence had not been presented to reopen the claim. The Veteran was informed of the decision and of her appellate rights, but she did not appeal that decision and it became final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.156 (b); 20.302, 20.1103 (2017); see also Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C.A. § 5108. The Veteran submitted a request to reopen her claim in April 2016. The evidence of record at the time of the May 2010 rating decision included the Veteran's service treatment records and post service treatment records. Service treatment records noted a diagnosis of hypertension in August 2002. Treatment records dated after 2002 documented treatment for hypertension. The evidence received since the prior final denial includes service treatment records and VA treatment records that document ongoing treatment for hypertension, after 2002. Also of record is the Veteran's testimony asserting that hypertension was diagnosed during service. In essence, her testimony raises the possibility that hypertension was diagnosed during a period of ACDUTRA. Such evidence is new as it was not previously of record. Moreover, such evidence must be presumed credible for the purposes of new and material evidence analysis. The evidence suggests that hypertension had onset during a period of ACDUTRA. Accordingly, as new and material evidence has been submitted, the claim for service connection for hypertension is reopened. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Further, a disability which is aggravated by a service connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran claims that her pre-existing flat feet were aggravated by service. She also claims service connection for bilateral plantar fasciitis, to include as secondary to pes planus. Initially, the Board notes that the competent medical evidence reflects diagnoses of bilateral pes planus and bilateral plantar fasciitis. She therefore has established current disabilities for purposes of continuing the service-connection analysis. Regarding in-service incurrence, the Board must first determine whether a bilateral foot disorder existed prior to the Veteran's service. A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment into service, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b). If a pre-existing disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under 38 U.S.C. § 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153 (2012); see also 38 C.F.R. § 3.306 (2008); Jensen, 19 F.3d at 1417. A pre-existing disease or injury will be found to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Evidence of the veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). A temporary or intermittent flare-up of a pre-existing disease does not constitute aggravation. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). The Veteran's service treatment records contain a June 1999 enlistment examination that noted mild pes planus, asymptomatic. No other foot abnormalities were noted at that time. As the Veteran's pes planus was noted on her enlistment examination, the presumption of soundness does not attach to that disability. Accordingly, in order to warrant service connection for pes planus, it must be shown that the disorder was aggravated by active service. The evidence of record does not show a permanent worsening of the Veteran's preexisting pes planus during or due to active service. In so finding, the Board notes that a service clinical treatment note in February 2004 also noted pes planus and painful arches. No other significant findings were reported. No further complaints or clinical findings regarding flat feet were recorded. The service treatment records also fail to show a diagnosis or clinical findings consistent with plantar fasciitis, and on separation from service the Veteran denied a history of foot trouble. After service, a March 2013 medical treatment report noted bilateral foot pain, flat feet for years, along with plantar fascial pain. In April 2013 it was noted that the Veteran had been diagnosed with bilateral plantar fasciitis by local providers and was going to physical therapy. She was also requesting custom orthotics. Subsequent treatment records show treatment for bilateral pes planus and plantar fasciitis. On VA examination in August 2013, the Veteran reported pain in the entire sole of the feet after being on her feet, during service. The examiner noted that the Veteran was issued generic orthotics and enrolled in physical therapy for her flat feet during military service. After service, she was issued custom orthotics for the feet that helped to improve the foot pain. She denied treatment with injections. Currently, she complained of daily pain rated as 9/10. She experienced achy pain when she first got out of bed. The pain would last about 30 minutes, and would then it would recur when walking or after periods of inactivity. The pain did not interfere with sleep. She denied numbness of the feet. Following a review of the claims file and an examination of the Veteran, the examiner opined that the Veteran's flat feet existed prior to entering military service and were not aggravated by service beyond its natural course and progression. In this regard, invasive therapy, such as injections or surgery, was not required for the feet while in the military, or thereafter. Rather, her symptoms continued to be successfully managed with orthotics and physical therapy. The examiner further associated the Veteran's symptoms with activity and weight gain. Concerning bilateral plantar fasciitis, the examiner concluded that the condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran developed plantar fasciitis as a consequence of her preexisting flat feet and obesity, both being risk factors for the development of plantar fasciitis. The Board assigns greatest weight to the opinion of the VA examiner in August 2013. The opinion was provided following review of the claims file and examination of the Veteran, considered the Veteran's contentions, provided an adequate rationale for the conclusion reached, and addressed the pertinent evidence of record. The examiner explained why the pre-existing bilateral pes planus was not aggravated by service, nor was bilateral plantar fasciitis incurred in service. The opinion contains an internal logic consistent with the known facts, as well as with other evidence of record. As such, the opinion is highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 -04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Indeed, to establish aggravation, the evidence must show a permanent worsening of the pre-existing condition, which is not documented in the service and post-service treatment records, and there is no competent evidence contemporaneous to service indicating that the pes planus permanently worsened. As noted above, the first post-service treatment in the record for the feet was many years after discharge from service. Currently, the Veteran's pes planus is managed as it had been in the past, with orthotics and physical therapy. Thus, the probative medical evidence indicates bilateral pes planus noted on service enlistment examination was not permanently worsened during service. The Board has considered the Veteran's contention that military service worsened her pes planus, as well as the contention that her plantar fasciitis is service related. While the Veteran is competent to report on what she sees and feels, such as mid-arch foot pain, the question whether preexisting pes planus was aggravated beyond its natural course by service, or whether plantar fasciitis is related to service, is a complex medical question, not capable of lay observation. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Because the evidence does not indicate that the Veteran has the appropriate training, experience, or expertise to provide a medical opinion concerning pes planus and plantar fasciitis, she is not competent to provide a medical opinion regarding any incurrence or aggravation of a foot disorder during or by service. See Jandreau v. Nicholson, 492 F.3d 1372, at 1376-77 (Fed. Cir. 2007. In this regard, the Board finds the service treatment records and post service medical evidence showing the extent of her pes planus, as well as an initial diagnosis of bilateral plantar fasciitis many years after service discharge, along with the opinion of the August 2013 VA examiner, to be more probative than the Veteran's lay assertions. To the extent the Veteran's plantar fasciitis has been associated with pes planus, as service connection for bilateral pes planus has not been established, there is no legal basis upon which to award service connection for bilateral plantar fasciitis on a secondary basis. 38 C.F.R. § 3.310. In sum, the evidence shows that pes planus pre-existed the Veteran's entry to service and did not permanently increase in severity during that service, and there is no competent evidence that links plantar fasciitis to service. Therefore, the Board finds that the preponderance of the evidence is against the claims for service connection for bilateral pes planus and bilateral plantar fasciitis, and the claims are denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER As new and material evidence has been presented, the claim for service connection for hypertension is reopened, and to this extent only the appeal is granted. Service connection for bilateral pes planus is denied. Service connection for bilateral plantar fasciitis is denied. REMAND Initially, concerning the claim for service connection for hypertension, while there are service personnel records associated with the record, it is unclear as to as the Veteran's specific periods of ACDUTRA and/or INACDUTRA. During the July 2017 hearing, the Veteran reported that hypertension was diagnosed during a period of ACDUTRA. Therefore, the AOJ should verify all periods of ACDUTRA and INACDUTRA, to specifically include in August 2002. Regarding the claim for entitlement to service connection for a right knee disorder, the service treatment records document complaints of bilateral knee pain, and treatment records in 2010 document an assessment of right patellofemoral syndrome. At the July 2017 Board hearing the Veteran asserted that the claimed right knee disorder is secondary to altered gait caused by her service-connected left knee disability. A VA examiner in December 2014 reported that the claimed right knee condition was at least as likely as not incurred in or caused by the claimed in-service injury, event or illness because the Veteran injured both knees in a March 2004 motor vehicle accident when both knees struck a dashboard. However, the examiner did not diagnose a right knee disorder and concluded that the condition had since resolved without residuals. The Board finds the VA medical opinion somewhat confusing and contradictory in its conclusions. While the examiner appeared to find that there was no right knee disorder, the examiner also opined that a right knee disorder was due to service. Given the confusing findings, the Board finds that a remand is warranted for a new examination to determine whether a right knee disability is present, and if so, whether it is related to service or the service-connected left knee condition. Next, pertaining to the claim for entitlement to service connection for a psychiatric disorder, during her hearing, she essentially reported that her current psychiatric disorder, variously diagnosed as bipolar disorder and generalized anxiety disorder, had onset in service. She described anxiety and panic attacks since service. The Veteran has not been afforded a VA examination to address the etiology of her psychiatric diagnoses to include whether they had onset during active duty as she has alleged. In light of the current psychiatric diagnoses, as well as the Veteran's competent statements concerning onset/continuity of psychiatric symptomatology, the Board finds a remand is warranted to adequately assess whether the Veteran has a current psychiatric disorder related to service. See McLendon v. Nicholson, 20 Vet App. 79, 83 (2006). Similarly, the Veteran described onset of gynecological symptoms during service, including painful heavy menses. Reportedly, she was treated for her symptoms with different contraceptives. Post-service treatment records show that the Veteran was seen for an ovarian cyst in 2009 and clinical treatment notes in 2014 recorded the Veteran's report that an ultrasound earlier that year revealed findings consistent with a diagnosis of endometriosis. Treatment records also include endometriosis as part of the Veteran's medical problem list. As the Veteran has not been afforded a VA examination to address the etiology of any gynecological disorders found to be present, in light of the "low threshold" as announced in McLendon, the Board finds that a remand is necessary for a VA examination. Id. Regarding the claim for an increased rating for Crohn's disease with diverticulitis and GERD, the Veteran was most recently afforded a VA examination in connection with her claim in 2014. However, at the July 2017 Board hearing, the Veteran asserted that her condition had increased in severity since she was last examined. VA's General Counsel has indicated that, when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). In light of the Veteran's contentions that her service-connected Crohn's disease with diverticulitis and GERD, has increased in severity and as the most recent examination of record is now more than three years old, a new examination to evaluate the severity of the Veteran's disability is warranted. Concerning the Veteran's claim for a compensable rating for the service-connected left knee disorder, the Board has reviewed the Veteran's most recent VA examination findings from November 2014, and concludes that these findings do not meet the specifications of Correia v. McDonald, 28 Vet. App. 158, 168-169 (2016). Although range of motion testing was conducted, the examiner did not indicate whether range of motion testing was conducted in active motion, passive motion, weight-bearing and nonweight-bearing. In Correia, the Court found that 38 C.F.R. § 4.59 requires that VA joint examinations must, where possible, include range of motion results 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. Id. at 165. Further, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the Board finds that a new VA examination is required. Given this, further examination is thus necessary under 38 C.F.R. § 3.159 (c) (4). When adjudicating the claims the AOJ should be mindful of the Court's holdings in DeLuca v. Brown, 8 Vet. App. 202 (1995) and Mitchell v. Shinseki, 25 Vet. App. 32 (2011) regarding painful motion. Finally, the claim for entitlement to a TDIU is inextricably intertwined with the claims for increased ratings for a left knee disorder and Crohn's disease with diverticulitis and GERD. Thus, adjudication of the TDIU claim is deferred. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Obtain all relevant outstanding VA treatment records. 2. Contact any appropriate source, to include the National Personnel Records Center, the Department of the Navy, and/or the Veteran's Navy Reserves unit, to verify the Veteran's periods of ACDUTRA and INACDUTRA, to specifically include in August 2002. In making these requests, use the Veteran's complete name, as listed on her Form DD 214. Follow the procedures set forth in 38 C.F.R. § 3.159 (c) with regard to requesting records from Federal facilities. All attempts to procure these records should be documented in the file. If the records cannot be obtained, a notation to that effect should be inserted in the file. The Veteran is to be notified in accordance with the regulatory provisions of 38 C.F.R. § 3.159 as to any unsuccessful efforts to obtain evidence and provided an opportunity to obtain and submit those records for VA review. 3. After the development requested above has been completed, schedule the Veteran for a VA psychiatric disability examination to address her claim for service connection for an acquired psychiatric disorder, to include bipolar disorder and anxiety disorder. The claims file must be provided to the examiner for review in conjunction with the examination. After review of the file and examination of the Veteran, the examiner should offer an opinion as to the following: a) The examiner should identify all psychiatric disorders found to be present. b) Determine whether it is at least as likely as not (a probability of 50 percent or greater) that any current psychiatric disorder had onset during service, had its onset in the year immediately following discharge from service, or is otherwise the result of a disease or injury in service. The examiner is advised that the Veteran is competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. All opinions expressed must be accompanied by a complete rationale. 4. Schedule the Veteran for a VA examination to address her claim for service connection for a gynecological disorder, to include endometriosis. The claims file must be provided to the examiner for review in conjunction with the examination. After review of the file and examination of the Veteran, the examiner should offer an opinion as to the following: a) The examiner should identify all gynecological disorders found to be present. b) Determine whether it is at least as likely as not (a probability of 50 percent or greater) that any current gynecological disorder had onset during service, or is otherwise the result of a disease or injury in service. The examiner is advised that the Veteran is competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The examiner shall attempt to reconcile the opinion with any other medical opinions of record. All opinions expressed must be accompanied by a complete rationale. 5. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of her Crohn's disease with diverticulitis and GERD. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected disability. The examiner should report all signs and symptoms necessary for evaluating the Veteran's Crohn's disease with diverticulitis and GERD, under the rating criteria, including whether the Veteran has: infrequent exacerbations; frequent exacerbations; numerous attacks a year and malnutrition, the Veteran's health only fair during remissions, or marked malnutrition, anemia and general disability should be characterized as moderate, moderately severe, severe, or pronounced. It should be noted that the Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptoms. 6. Schedule the Veteran for a VA examination to assess the current severity of the service-connected left knee disability, and to determine whether a right knee disability is related to service or a service-connected disability. The Veteran's claims file should be made available to and reviewed by the examiner, and he or she must indicate whether such review was accomplished. Following a review of the relevant evidence, the examiner must address the following questions: a) The examiner should identify any right knee disorders found on examination. b) Is it at least as likely as not (50 percent probability or greater) that any diagnosed right knee disability is related to service? c) If not incurred in service, is it at least as likely as not (50 percent or greater degree of probability) that any diagnosed right knee condition was caused by her service-connected left knee disability, to include any gait disturbance and weight shifting? d) If not caused by the service-connected left knee disability, is it at least as likely as not (50 percent or greater degree of probability) that any diagnosed right knee condition is permanently worsened in severity beyond the natural progress of the condition (as opposed to a temporary exacerbation of symptoms) by the service-connected left knee disability, to include any gait disturbance and weight shifting? If a permanent worsening of the Veteran's right knee disability beyond natural progression is found (aggravation), the examiner should, to the extent possible, attempt to quantify the amount of worsening of the right knee disability beyond the baseline level of that disability that is due to the service connected left knee disability. e) The examiner should determine the range of motion of the Veteran's right and left knees in degrees. Range of motion testing must include both passive and active motion, and in weight-bearing and nonweight-bearing conditions. It should be indicated whether and at what point during the Veteran's range of motion the Veteran experiences any limitation of motion that is specifically attributable to pain. Further, the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use, weakened movement, excess fatigability, or incoordination should be indicated. If the Veteran endorses flare-ups of symptoms the examiner must comment on the functional limitations of the left knee during flare-ups, and the effect of pain on range of motion. If there is no flare-up at the time of the examination, the examiner is asked to opine on further functional limitations based on the Veteran's subjective complaints and history. f) The examiner should state whether there is left knee instability that is best characterized as moderate or severe. g) The examiner should assess the impact of the Veteran's service connected left knee disability on her activities of daily living, including her occupational functioning. All findings, conclusions, and the rationale for all opinions expressed should be provided in a report. Please note that an examiner's report that she/ he cannot provide and opinion without resort to mere speculation is inadequate unless the examiner provides a rationale for that statement. 7. Then, readjudicate the Veteran's claims on appeal, to include the claim for entitlement to a TDIU. If the benefits sought on appeal remain denied, the Veteran and her representative should be provided a supplemental statement of the case. Allow an appropriate period of time for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Cynthia M. Bruce Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs