Citation Nr: 21063417 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-43 443 DATE: October 14, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim for service connection for posttraumatic stress disorder (PTSD), to that extent only, is granted. Entitlement to an increased rating in excess of 10 percent for lumbosacral strain is denied. Entitlement to an increased for a rating in excess of 10 percent for left knee patellofemoral pain syndrome is denied. Entitlement to an initial increased rating in excess of 10 percent for right knee patellofemoral pain syndrome is denied. Entitlement to service connection for a left hip condition is granted. Entitlement to service connection for a right hip condition is granted. REMANDED Entitlement to service connection for a bilateral eye condition is remanded. Entitlement to an acquired psychiatric disorder, to include PTSD, anxiety, depression, unspecified trauma and stressor related disorder, and insomnia is remanded. Entitlement to service connection for a bilateral wrist condition is remanded. FINDINGS OF FACT 1. An April 2015 rating decision denying the Veteran's claim of service connection for PTSD became final after a failure to appeal. 2. Evidence added to the record since the most recent final rating decision presents a reasonable possibility of substantiating the Veteran's PTSD claim on the merits. 3. The Veteran's lumbosacral strain is manifest by forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees and painful motion. 4. The Veteran's left knee patellofemoral pain syndrome is manifest by limited flexion and painful motion. 5. The Veteran's right knee patellofemoral pain syndrome is manifest by limited flexion and painful motion. 6. The Veteran's left hip condition is related to his service, including the physical requirements necessary to earn an Air Assault Badge. 7. The Veteran's right hip condition is related to his service, including the physical requirements necessary to earn an Air Assault Badge. CONCLUSIONS OF LAW 1. The RO's April 2015 denial of service connection for PTSD is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.200, 20.302, 20.1103. 2. New and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for PTSD. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. The criteria for entitlement to an increased rating in excess of 10 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 4. The criteria for entitlement to an increased for a rating in excess of 10 percent for left knee patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 5. The criteria for entitlement to an initial increased rating in excess of 10 percent for right knee patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 6. The criteria for entitlement to service connection for a left hip condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for a right hip condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the Army from July 2009 to July 2014, to include service in both Iraq and Afghanistan. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2016, November 2017, and February 2019 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). While the Veteran has expressly filed a claim of service connection for depression, anxiety, and PTSD, in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board finds that it is appropriate to recharacterize the claim more broadly as one of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety, depression, unspecified trauma and stressor related disorder, and insomnia. In the August 2017 and March 2020 VA Form 9s, the Veteran elected a video conference hearing; however, the Veteran withdrew that request in January 2021 Third Party Correspondence. As such, no hearing was held, and the Veteran's claims will be adjudicated based on the evidence of record. NEW AND MATERIAL EVIDENCE 1. Whether new and material evidence was received the reopen the Veteran's claim of service connection for PTSD The Board is required to consider the question of whether new and material evidence has been received to reopen the claim without regard to the RO's determination in order to establish the Board's jurisdiction to address the underlying claim and to adjudicate the claim on a de novo basis. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. If a claim of entitlement to 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; see also Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156 (a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. In determining whether evidence is new and material, the credibility of the new evidence must be presumed. See Justus v. Principi, 3 Vet. App. 510 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Here, an April 2015 rating decision denied the Veteran's original claim of service connection for PTSD. He did not appeal this determination, and no new material evidence was submitted within a year following notification of the April 2015 denial. The April 2015 rating decision is therefore final. The prior final decision denying service connection for PTSD was based on the finding that the evidence did not show a confirmed clinical diagnosis of PTSD. Additionally, the RO found that there was no evidence to show a specific verified in-service stressor. The Veteran filed a new claim in September 2017, which was subsequently denied in November 2017. The RO reopened the Veteran's claim in the subsequent January 2020 statement of the case; however, the Board is not bound by the RO's finding. See Butler v. Brown, 9 Vet. App. 167, 171 (1996). The Board finds that new and material evidence has been presented sufficient to reopen the claim. New evidence includes a November 2018 Disability and Benefits Questionnaire completed by Dr. J.A. and a June 2019 VA examination. The evidence is new as it is not cumulative or redundant of the evidence of record at the time of the previous decision. It is also material, as it relates to an unestablished fact necessary to substantiate the claim (specifically, details regarding whether the Veteran has a diagnosis of PTSD) and raises a reasonable possibility of substantiating the claim. The Board finds that new and material evidence has been submitted as to the claim of service connection for PTSD. Accordingly, this claim is reopened. Increased Ratings Disability ratings are determined by the application of the facts presented to VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. 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 service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claim for increased rating remains in controversy when less than the maximum available benefit is awarded AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the Veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). 1. Entitlement to an increased rating in excess of 10 percent for lumbosacral strain The Veteran contends that his currently service-connected lumbosacral strain is more severe than as reflected in his current 10 percent rating. The Veteran's current lumbosacral strain disability is evaluated under Diagnostic Code 5237 for lumbosacral or cervical strain, which evaluates conditions using the General Rating Formula for Diseases and Injuries of the Spine under 38 C.F.R. § 4.71a. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent evaluation is warranted if the forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; there is muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Normal ranges of motion of the thoracolumbar spine are flexion from 0 to 90 degrees, extension from 0 to 30 degrees, lateral flexion from 0 to 30 degrees, and lateral rotation from 0 to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, Plate V. Note 1 indicates that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment should be separately evaluated under rhe appropriate diagnostic code. 38 C.F.R. § 4.71a. The Board notes that the Veteran filed his claim for an increased evaluation on September 7, 2017; the Board has considered the evidence of record since September 7, 2016 in conjunction with this decision. See 38 C.F.R. § 3.400 (o). Evidence relevant to the current claim includes an October 2017 VA examination. The examiner diagnosed the Veteran with lumbosacral strain. The Veteran reported flare-ups related to changing positions, such as while driving. He denied functional loss or impairment of the spine. Upon range of motion testing, his forward flexion was limited to 80 degrees with a combined range of motion of the thoracolumbar spine of 195 degrees. Pain was noted upon motion, but it did not result in functional loss. The Veteran was able to perform observed repetitive use testing without additional loss of function or range of motion. As for repeated use over time or during flare-ups, the examiner opined that he was unable to say without speculation whether pain, weakness, fatigability, or incoordination would significantly limit functional ability. The rationale provided was that flare-ups and repeated range of motion variations are unpredictable and extremely variable in their severity and are therefore dependent on various physical activities as well as environmental factors. There was no objective evidence of guarding or muscle spasms, muscle atrophy, radiculopathy, ankylosis, neurological abnormalities, or intervertebral disc syndrome (IVDS). The Veteran was afforded another VA examination in June 2019. The Veteran was diagnosed with lumbar strain and degenerative arthritis of the spine. The Veteran reported flare-ups related to prolonged standing and ambulation as well as constant changing positions. He denied any functional loss or impairment. Upon range of motion testing, his forward flexion was limited to 70 degrees and his combined thoracolumbar range of motion was 165 degrees. Pain was noted on the examination, but it did not cause functional loss. The Veteran was able to perform repetitive use testing without additional loss of function or range of motion. After repeated use over time and during flare-ups, the examiner opined that pain, weakness, fatigability, or incoordination would not significantly limit functional ability. There was no objective evidence of guarding or muscle spasms, muscle atrophy, radiculopathy, ankylosis, neurological abnormalities, or IVDS. After careful consideration of the evidence, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for lumbosacral strain. Both the October 2017 and June 2019 VA examinations determined that the Veteran's forward flexion was limited to no less than 70 degrees, which warrants a 10 percent evaluation. The Veteran's combined thoracolumbar spine range of motion was no less than 165 degrees, which also warrants only a 10 percent evaluation. There was no evidence of guarding or muscle spasms to warrant a rating greater than 10 percent. Furthermore, the Veteran denied functional loss due to his lumbosacral strain condition during both the October 2017 and June 2019 VA examinations. Also, the Veteran reported experiencing flare-ups when driving, or during prolonged standing and ambulation, but the June 2019 VA examiner opined that pain, weakness, fatigability, or incoordination would not significantly limit functional ability. Thus, due to the minimal severity of the Veteran's flare-ups, the Board finds that there is no evidence to support finding that the degree of additional limitation reflected would result in limitation of motion more nearly approximating 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. Regarding neurological impairment, the October 2017 and June 2019 VA examinations did not find any evidence indicating that the Veteran has any neurological abnormalities associated with his spine disability. As for the Veteran's diagnosis of degenerative arthritis of the spine as noted in the October 2019 VA examination, the Board has considered whether a separate rating is warranted. However, the Board finds that pursuant to Diagnostic Code 5003 for degenerative arthritis, the condition is to be rated on the basis of limitation of motion for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. As the Veteran's lumbosacral strain is adequately evaluated under Diagnostic Code 5237 based on limited motion and painful motion, the Board finds that a separate rating under Diagnostic Code 5003 would violate the rule against pyramiding. 38 C.F.R. § 4.14. The Board acknowledges that the Veteran contends that his lumbosacral strain has increased in severity throughout the duration of the appeal and warrants a higher evaluation. Although the Veteran is competent to report his observable symptoms, the competent medical evidence offering detailed determination pertinent to the claims are the most probative evidence with regard to evaluating the disability on appeal. Layno v. Brown, 6 Vet. App. 465 (1994). The Board has also considered statements made in the Veteran's representative's March 2021 Third Party Correspondence, specifically that the Veteran was not evaluated during a flare-up in October 2017 and is thus entitled to a new examination. However, the Veteran was awarded a new VA examination in October 2019 and after evaluating the Veteran's statements regarding flare-ups, the examiner opined that the Veteran's flare-ups would not significantly limit his functional ability. Additionally, the record does not contain any additional evidence indicating that the Veteran's flare-ups are more severe than reported by him during his October 2017 and June 2019 VA examinations. Consequently, the Board finds that a new VA examination is not warranted. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for lumbosacral strain. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an increased for a rating in excess of 10 percent for left knee patellofemoral pain syndrome 3. Entitlement to an initial increased rating in excess of 10 percent for right knee patellofemoral pain syndrome The Veteran contends that his currently service-connected left and right knees patellofemoral pain syndrome is more severe than as reflected in his current 10 percent rating. The Veteran's current bilateral knee disabilities are evaluated under Diagnostic Code 5260 for limitation of flexion under 38 C.F.R. § 4.71a. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board notes that the Veteran filed her claim for increased evaluation on September 7, 2017; the Board has considered the evidence of record since September 7, 2016 in conjunction with this decision. See 38 C.F.R. § 3.400 (o). Evidence relevant to the Veteran's claim includes an October 2017 VA examination. The Veteran was diagnosed with patellofemoral syndrome of both knees. He reported flare-ups related to changing positions, ascension and descension of stairs, and running. He denied any functional loss or impairment due to his bilateral knee disability. Upon range of motion testing, his right knee was normal with flexion to 140 degrees and extension to 0. Pain was noted on the examination but did not result in functional loss. The Veteran's left knee flexion was limited to 120 degrees and his extension to 0. Pain was noted on the examination but did not result in functional loss. After observed repetitive use testing, there was no additional loss of function or range of motion. After repeated use over time and during flare-ups, the examiner opined that he was unable to say without speculation whether pain, weakness, fatigability, or incoordination would significantly limit functional ability. The reasoning provided was that flare-ups and repeated range of motion variations are unpredictable and extremely variable in their severity and therefore are dependent on various physical activities as well as environmental factors. There was no evidence of muscle atrophy, ankylosis, joint instability, or meniscal conditions. Another VA examination was completed in June 2019. The Veteran was diagnosed with patellofemoral pain syndrome of both knees. He reported flare-ups related to prolonged knee flexion positions and activities that increase force in his knee joint. The Veteran denied any functional loss due to his bilateral knee condition. Upon range of motion testing, his right knee was normal with flexion to 140 degrees and extension to 0. Pain was noted, but it does not result in functional loss. His left knee flexion was limited to 120 degrees and extension to 0. Pain was noted on the examination but does not cause functional loss. The Veteran was able to perform repetitive use without additional loss of function or range of motion. After repeated use over time and during flare-ups, the examiner opined that pain, weakness, fatigability, or incoordination do not significantly limit functional ability. There was no evidence of muscle atrophy, ankylosis, or joint instability. The examiner noted a history of recurrent effusion. The Veteran reported left knee effusions with prolonged standing and ambulation and exercises that increase internal knee forces. The examiner also noted shin splints on both legs, not affecting the range of motion of the knees. The Veteran denied any current shin splint symptoms but stated that he cannot run due to chronic knee pain. There was no evidence of meniscal conditions. After careful consideration of the evidence, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for bilateral patellofemoral pain syndrome. As for the right knee, both the October 2017 and June 2019 VA examinations show that the Veteran has full range of motion, but experiences pain on motion. Thus, a 10 percent rating is an accurate reflection of the Veteran's right knee symptoms throughout the appeal. As for the left knee, the Veteran's flexion was limited to no less than 120 degrees, which is noncompensable under Diagnostic Code 5260. However, as the Veteran experienced pain upon motion of the left knee, a 10 percent rating is an accurate reflection of his left knee symptoms throughout the appeal. The Veteran denied functional loss due to his bilateral patellofemoral pain syndrome condition during both the October 2017 and June 2019 VA examinations. He did report experiencing flare-ups when changing positions, while ascending and descending stairs, and while running, but the June 2019 VA examiner opined that pain, weakness, fatigability, or incoordination would not significantly limit the Veteran's functional ability. The Board finds that there is no evidence to support finding that the degree of additional limitation reflected would result in limitation of motion more nearly approximating flexion limited to 30 degrees to warrant an increased rating. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, in this case, there are no additional symptoms to warrant separate compensable ratings. The Board acknowledges that the Veteran contends that his knee buckles and his knee has deteriorated over time warranting a higher evaluation. See March 2021 Third Party Correspondence. Although the Veteran is competent to report his observable symptoms, the competent medical evidence offering detailed determination pertinent to the claims are the most probative evidence with regard to evaluating the disability on appeal. Layno v. Brown, 6 Vet. App. 465 (1994). Neither the October 2017 nor the June 2019 VA examinations noted any evidence of knee instability, and the right knee's range of motion has been normal throughout the appeal. Finally, the Board has considered the March 2021 Third Party Correspondence authored by the Veteran's representative. The representative contended that the Veteran's knee symptoms have worsened since the October 2017 VA examination entitling the Veteran to a new VA examination. However, the Veteran was afforded a new VA examination in June 2019 and there is no objective evidence to suggest that the Veteran's knee symptoms have increased since the June 2019 VA examination. Accordingly, the Board finds that the Veteran is not entitled to a new VA examination to evaluate his current knee symptoms. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for left knee and right knee patellofemoral pain syndrome. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. SERVICE CONNECTION 1. Entitlement to service connection for a left hip condition 2. Entitlement to service connection for a right hip condition The Veteran contends that he has a bilateral hip condition which was caused by his military service. Specifically, he contends that he went through Air Assault school where he engaged in hundreds of ruck marches and repelled numerous times causing a lot of back and hip problems. See January 2019 Medical Treatment Record. Generally, service connection may be established if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. To that end, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R. § 3.303 (d). In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's service treatment records include an April 2014 separation physical and post-deployment health assessment. The Veteran indicated pain in his joints, to include the hips, which bothered him a little after returning from deployment. There are no other notations for diagnoses or treatment related to a hip condition. The Veteran's DD-214 indicates that the Veteran did in fact receive an Air Assault Badge. The Veteran's VA treatment records include an October 2016 primary care note where the Veteran complained that his hips were "popping." The physician noted that the Veteran had limited internal and external rotation of both his hips with pain on motion. It was also noted that the Veteran had an altered gait with his left foot slightly "pigeon toed." He was assessed with hip pain and x-rays were ordered. A November 2016 letter indicated that the Veteran's hip x-rays showed some borderline mild arthritic subchondral sclerosis at each hip with vacuum phenomena on the right. The x-rays also revealed hypertrophy at the upper outer portion of each femoral neck/head junction suggesting femoral acetabular impingement. The remainder of the Veteran's VA treatment records note a diagnosis of hip impingement syndrome for which the Veteran sought continuous treatment. The Veteran provided a medical opinion in January 2019 from Dr. J.D. regarding the etiology of the Veteran's bilateral hip condition. Dr. J.D. referenced a statement from the Veteran where he stated that while in Air Assault school, he completed hundreds of ruck marches and repelled numerous times causing hip problems. He further noted that when he repelled from ropes, he landed on his feet which sent a jolt through his body as he landed on the ground pretty hard. After reviewing the Veteran's statements and medical records, Dr. J.D. opined that it is at least as likely as not that the Veteran's current hip problems are related to his military service. The rationale provided was that the Veteran had no prior history of injury prior to the service and the activity he engaged in while in the military would certainly be an adequate mechanism to develop the changes seen on his hips. The Board finds Dr. J.D.'s opinion to be adequate and probative as it is based on an accurate medical history and provides an explanation that contains clear conclusions with supporting data. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). After careful consideration of the evidence, the Board finds that the preponderance of the evidence supports finding that the Veteran has a currently diagnosed bilateral hip condition that is related to his service. The Veteran's VA treatment records indicate that he was diagnosed with bilateral hip arthritis in October 2016 and bilateral hip impingement syndrome. The Veteran's DD-214 shows that the Veteran earned an Air Assault Badge, and his service treatment records show complaints of hip pain in April 2014. Further, Dr. J.D. provided a probative opinion determining that the Veteran's current hip condition is at least as likely as not related to the physical training the Veteran engaged in during Air Assault school. Undoubtedly, further medical inquiry could be undertaken with a view towards further developing this claim. However, in this regard, the United States Court of Appeals for Veterans Claims has cautioned VA against seeking an additional medical opinion where favorable evidence in the record is unrefuted (or, at worst, evenly balanced for and against the claim) and indicated that it would not be permissible to undertake further development in this circumstance if the sole purpose was to obtain evidence against an appellant's claim. Mariano v. Principi, 17 Vet. App. 305, 312 (2003). As the January 2019 opinion offered by Dr. J.D. is the only probative medical opinion of record, the Board concludes that the evidence is in favor of finding that the Veteran has a current bilateral hip condition related to his military service. Accordingly, entitlement to service connection for a bilateral hip condition is granted. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to decide on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 1. Entitlement to service connection for a bilateral eye condition is remanded. The Veteran contends that he has an eye condition that is related to environmental exposures while he was deployed to Iraq and Afghanistan. The Veteran's medical records indicate that he was diagnosed with bilateral giant papillary conjunctivitis in 2016. In his June 2016 notice of disagreement, the Veteran stated that during service, he had a thick, sandy textured, yellowish colored fluid that would drain from his eyes throughout the day and night and would cause a thick, crusty substance to form on his eyes every morning sealing his eyes shut. The Board notes that a VA examination or opinion must be obtained if there is (1) competent evidence of a current disability; (2) evidence of an in-service event, injury, or illness; (3) an indication that a current, claimed disability may be associated with the Veteran's service or another service-connected disability; and (4) the record contains insufficient competent medical evidence to make a decision. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds that the Veteran is entitled to a VA examination to determine whether the Veteran's bilateral eye condition is related to his in-service exposure to environmental hazards while deployed in both Iraq and Afghanistan. Id at 83. Accordingly, a remand is necessary to obtain a VA examination. 2. Entitlement to an acquired psychiatric disorder, to include PTSD, anxiety, depression, unspecified trauma and stressor related disorder, and insomnia is remanded. The Veteran contends that he has a diagnosis of an acquired psychiatric disorder that is related to his service. Throughout the appeal, the Veteran has provided several stressor statements to examining medical personnel. Specifically, during a February 2015 VA examination, the Veteran identified in-service stressors related to his duties as a military policeman at Fort Campbell, to include a stabbing of a fellow military policeman, a guy beat his wife when he was drunk killing her, he had to cut a guy down who had hanged himself, a guy shot himself in the hospital parking lot and his brains were all over the car window, a soldier hanged himself and he had to cut the soldier down, and a soldier was on cocaine and raped and beat a girl and the Veteran participated in the trial. During a recent June 2019 VA examination, the Veteran's reported stressors were related to his deployments to Iraq and Afghanistan. The Veteran's stressors include the sounds of sirens that go off from incoming, trash on the side of the road makes him recall objects like IEDs, and a rocket landed 6 feet from the door of his room in Kandahar, Afghanistan. The Board finds that a remand is required to allow VA to attempt to corroborate the Veteran's reported stressors. The Veteran has also undergone several mental health evaluations with varying findings. In February 2015, the VA examiner opined that the Veteran did not meet the diagnostic criteria for PTSD but did have a diagnosis of unspecified trauma and stressor related disorder. The examiner opined that his diagnosis is more likely than not a direct result of his in-service military stressors. However, the examiner did not provide a rationale for this opinion. In November 2018, the Veteran was evaluated by Dr. J.A. who determined that the Veteran did meet the DSM-5 diagnostic criteria for a PTSD diagnosis, but found that the Veteran's symptoms were not severe enough to interfere with occupational or social functioning or require continuous medication due to a diagnosis of alexithymia. However, Dr. J.A. did not identify how he determined the Veteran had a diagnosis of alexithymia and what diagnostic criteria was used to find that the Veteran had this diagnosis, which apparently minimizes his symptoms. During the June 2019 VA examination, the examiner opined that the Veteran does not meet diagnostic criteria for PTSD and does not have a mental disorder that conforms with DSM-5. The examiner referred to the November 2018 evaluation with Dr. J.A. and found that the diagnosis of alexithymia was "questionable" and "a weak attempt to explain or account for the Veteran's lack of key symptoms." However, the examiner did not further elaborate on why the diagnosis of alexithymia was "questionable," and did not consider the February 2015 VA examination diagnosing the Veteran with unspecified trauma and stressor related disorder. Finally, the Veteran's VA treatment records include a February 2015 mental health evaluation diagnosing the Veteran with insomnia disorder. However, neither the VA examiners nor Dr. J.A. addressed whether the Veteran has a diagnosis of insomnia that is related to his service. The Board finds that an updated VA examination is necessary to consider all the evidence of record and to determine whether the Veteran has a diagnosis of PTSD, anxiety, depression, unspecified trauma and stressor related disorder, or insomnia disorder, or has had a diagnosis of one of these conditions during the pendency of the appeal. Additionally, the examiner needs to consider and reconcile the opinions offered by the February 2015 VA examiner, the June 2019 VA examiner, and Dr. J.A. Also, the examiner needs to consider Dr. J.A.'s diagnosis of alexithymia and whether the Veteran meets the diagnostic criteria, and if, and/or how the diagnosis may affect other mental health diagnoses. 3. Entitlement to service connection for a bilateral wrist condition is remanded. The Veteran contends that his diagnosis of bilateral ganglion wrist is related to his service. The Veteran was afforded a VA examination for his bilateral wrist condition in February 2015. However, the VA examiner did not offer an opinion as to the nature and etiology of the wrist condition and whether it is related to service. Accordingly, the Board finds that a new VA examination is necessary. The matters are REMANDED for the following actions: 1. Attempt to corroborate the Veteran's in-service stressor, including the noncombat-related stressors reported during the February 2015 VA examination and the combat related stressors reported during the June 2019 VA examination. If more details are needed, contact the Veteran to request the information. 2. After the above-referenced development is completed, schedule the Veteran for a VA examination with an appropriate clinician for his claimed bilateral eye condition, to include his diagnosis of giant papillary conjunctivitis. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran's bilateral eye condition at least as likely as not related to service, including his exposure to environmental hazards while deployed in both Iraq and Afghanistan? When rendering an opinion, please consider and address the Veteran's June 2016 statement provided in his notice of disagreement, where he stated that during active service, he had a thick, sandy textured, yellowish colored fluid that would drain from his eyes throughout the day and night causing a thick, crusty substance to form on his eyes every morning sealing his eyelids shut. Any opinion expressed should be accompanied by a complete rationale. 3. Schedule the Veteran for a VA examination with an appropriate clinician for his claimed bilateral wrist disability, to include his diagnosis of ganglion cyst of the wrists. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran's diagnosis of bilateral ganglion cysts least as likely as not related to service? When rendering an opinion, the examiner to asked to consider and address the February 2015 VA examination. Any opinion expressed should be accompanied by a complete rationale. 4. After the Veteran's reported stressors have been developed, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. The examiner is asked to specifically consider and address whether the Veteran has current diagnoses of or has been diagnosed during the course of the appeal with anxiety, depression, insomnia disorder, and/or unspecified trauma and stressor related disorder; and offer an opinion as to whether any of these diagnosed conditions are at least likely as not related to the Veteran's service, to include the verified stressors. The examiner is also asked to specifically consider and reconcile the evaluations and opinions offered by the February 2015 VA examiner, the June 2019 VA examiner, and the November 2018 opinion by Dr. J.A. Finally, the examiner must address and consider the diagnosis of alexithymia provided by Dr. J.A. The examiner is asked to offer an evaluation and opinion as to whether the Veteran has a diagnosis of alexithymia, and if he does, how the alexithymia impacts any other diagnosed psychiatric disorder. Any opinion expressed should be accompanied by a complete rationale. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Hartford, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.