Citation Nr: 21073598 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 17-45 451 DATE: December 9, 2021 ORDER New and material evidence having been received, the Veteran's request to reopen a claim of service connection for a left knee disability is granted; to that extent only the appeal is granted. Relevant official service department records that existed but were not associated with the claims file when VA first decided the claim having been received, the claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is reconsidered. Whether new and material evidence has been received to reopen a claim of service connection for a right hip disability has been withdrawn. Entitlement to compensation for diabetes mellitus pursuant to 38 U.S.C. § 1151 has been withdrawn. Entitlement to service connection for a bilateral shoulder disability has been withdrawn. Entitlement to service connection for a disability manifested by acid reflux has been withdrawn. Entitlement to service connection for a bilateral hand disability has been withdrawn. Entitlement to service connection for a bilateral elbow disability has been withdrawn. Entitlement to service connection for a disability manifested by weakness has been withdrawn. Entitlement to service connection for obesity has been withdrawn. Entitlement to service connection for hiatal hernia has been withdrawn. Entitlement to service connection for a cervical spine (neck) disability has been withdrawn. Entitlement to service connection for osteoarthritis has been withdrawn. Entitlement to an initial compensable rating for menorrhagia/fibroid uterus has been withdrawn. REMANDED Entitlement to service connection for a bilateral foot (heel) disability is remanded. Entitlement to service connection for an acquired psychiatric disability, to include PTSD, is remanded. Entitlement to service connection for a thoracolumbar spine (back) disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to an initial rating in excess of 10 percent for right knee strain. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. A March 2011 rating decision denied service connection for left knee strain. The Veteran did not appeal that decision; and new and material evidence was not received prior to expiration of the appeal period. Evidence received since the March 2011 rating decision relates to unestablished facts necessary to substantiate the claim for service connection for left knee strain. 2. The March 2011 rating decision denied service connection for PTSD. Evidence received since the March 2011 rating decision includes relevant official service department records that existed but were not associated with the claims file. 3. On October 15, 2019, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, through her attorney, that a withdrawal of this appeal was requested with respect to the issues of whether new and material evidence has been received to reopen a claim of service connection for a right hip disability; entitlement to compensation for diabetes mellitus pursuant to 38 U.S.C. § 1151; entitlement to service connection for a bilateral shoulder disability, a disability manifested by acid reflux, a bilateral hand disability, a bilateral elbow disability, a disability manifested by weakness, obesity, a hiatal hernia, a cervical spine (neck) disability, osteoarthritis; and entitlement to an initial compensable rating for menorrhagia/fibroid uterus. CONCLUSIONS OF LAW 1. The March 2011 rating decision denying service connection for left knee strain is final. 38 U.S.C. §§ 7105 (c); 38 C.F.R. § 20.1103. New and material evidence has been received since the March 2011 rating decision, and the claim of entitlement to service connection for a left knee disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156. 2. Relevant official service department records submitted in May 2013 were in existence in March 2011 and are relevant to the claim for entitlement to service connection for PTSD. 38 C.F.R. § 3.156 (c). 3. The criteria for withdrawal of an appeal by the Veteran have been met with respect to the issues of whether new and material evidence has been received to reopen a claim of service connection for a right hip disability; entitlement to compensation for diabetes mellitus pursuant to 38 U.S.C. § 1151; entitlement to service connection for a bilateral shoulder disability, a disability manifested by acid reflux, a bilateral hand disability, a bilateral elbow disability, a disability manifested by weakness, obesity, a hiatal hernia, a cervical spine (neck) disability, osteoarthritis; and entitlement to an initial compensable rating for menorrhagia/fibroid uterus. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Army National Guard and had a period of initial active duty for training (ACDUTRA) from November 2007 to May 2008 with additional Army National Guard service until July 2010. As noted in detail below, the issue of entitlement to service connection will be reconsidered pursuant to 38 C.F.R. § 3.156 (c)(1). Thus, the issues of entitlement to various psychiatric disorders have been combined and recharacterized into the issue of entitlement to service connection for an acquired psychiatric disability, to include PTSD. Service connection may be granted for disability resulting from disease or injury incurred during ACDUTRA, or injuries suffered during inactive duty training (INACDUTRA) to include when a cardiac arrest or a cerebrovascular accident occurs during such training. See 38 U.S.C. §§ 101 (24), 106. Reserve and National Guard service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c). Basically, this refers to the two weeks of annual training that each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101 (23); 38 C.F.R. § 3.6 (d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year. These drills are deemed to be part-time training. Army National Guard Retirement Points History Statement indicates that the Veteran had 193 active duty points from November 6, 2007 to May 16, 2008 which correspond to Veteran's active duty for training period. There are 18 inactive duty points from July 6, 2007 to November 5, 2007 and 57 inactive duty points from May 15, 2008 to July 6, 2009. REQUEST TO REOPEN PREVIOUSLY-DENIED CLAIMS A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing 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 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. 38 C.F.R. § 3.156 (a). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. A finally adjudicated claim is an application which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. See 38 U.S.C. §§ 7105 (c); 38 C.F.R. § 20.1103. Under 38 C.F.R. § 3.156 (c)(1), at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. Such records include, but are not limited to, additional service records forwarded by the Department of Defense or the service department to VA any time after VA's original request for service records. An award based in whole or in part on these additional service department records is effective on the date entitlement arose or the date VA received the previously denied claim, whichever is later. 38 C.F.R. § 3.156 (c)(3). A March 2011 rating decision denied service connection for left knee strain on the basis that such neither occurred in nor was caused by service. That decision also denied service connection for PTSD on the basis that the record was absent credible evidence that the claimed stressor occurred and a confirmed diagnosis of PTSD. The Veteran did not appeal the March 2011 decision; and new and material evidence was not received prior to expiration of the appeal period. Thus, the March 2011 decision is final. Based on the grounds stated for the denial of service connection for a left knee disability in the March 2011 rating decision, new and material evidence would consist of evidence that the Veteran has a left knee disorder resulting from disease or injury incurred during ACDUTRA, or resulting from injury suffered during INACDUTRA. Since the March 2011 rating decision, VA has received a medical opinion from Dr. Donald Miller that the Veteran's left knee chondromalacia of the patella/femoral joint developed due to overuse during active duty. Dr. Miller noted that there is a notation during the Veteran's AIT training between March and May 2008 where the Veteran was seen by a doctor for problems pertaining to her "knees" and that a February 2008 document notes an overuse syndrome with respect to the Veteran's right knee with complaints that her knees had been hurting her ever since she started AIT. As such, the Board finds that the evidence received since the March 2011 rating decision is new and material and serves to reopen the claim for service connection for a left knee disability. With respect to the Veteran's previously-denied claim for service connection for PTSD, additional service department records relevant to this issue were received. Specifically, a DA Form 1559, Inspector General Action Request, dated August 28, 2009, and signed by the Veteran requested support with stalking and false entrapment by stalkers. Given the submission of this new service department record, the Veteran's service connection claim for PTSD must be reconsidered without regard to the previous denial. 38 C.F.R. § 3.156 (c). Request for Withdrawal of Claims The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, the Veteran, through her authorized representative, has withdrawn the appeal with respect to the issues of whether new and material evidence has been received to reopen a claim of service connection for a right hip disability; entitlement to compensation for diabetes mellitus pursuant to 38 U.S.C. § 1151; entitlement to service connection for a bilateral shoulder disability, a disability manifested by acid reflux, a bilateral hand disability, a bilateral elbow disability, a disability manifested by weakness, obesity, a hiatal hernia, a cervical spine (neck) disability, osteoarthritis; and entitlement to an initial compensable rating for menorrhagia/fibroid uterus. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal with respect to these issues, and it is dismissed. REASONS FOR REMAND Initially, a December 2012 statement from Social Security Administration (SSA) notes that she was found to have become disabled on March 31, 2010. As there appear to be outstanding and relevant SSA records, a remand is required to allow VA to request these records. Entitlement to service connection for a bilateral foot (heel) disability Report of Medical Examination in May 2007 for enlistment into the National Guard indicated clinical evaluation of the Veteran's feet to be abnormal; moderate hallux valgus and bunions without symptoms were noted. National Guard records indicate that the Veteran sprained her right ankle in January 2009; in March 2009, right ankle was nontender with full active range of motion and noted to be healed. In June 2009, the Veteran's foot was noted to be a lot better now from work injury. X-ray in January 2012 showed mild bilateral hallux valgus deformity and questionable hypertrophic changes at the plantar lateral aspect of the calcaneus which may be better evaluated with Harris Beath view. A March 2012 podiatry clinic note indicates that the Veteran was seen with a complaint of pain in both feet due to bunions. A c-shaped foot was noted upon weight bearing with a prominent styloid process bilateral and resting calcaneal stance position, 3 degree varus. A November 2012 podiatry note indicated that the Veteran presented for follow up of hallux valgus deformity was related to foot pronation and first ray hypermobility and elevated IM angle. X-ray in April 2013 showed bilateral heel spurs and degenerative changes in the talonavicular joint space bilaterally. X-ray in August 2015 showed no acute fracture or dislocation in the bilateral feet, slight interval progression of bilateral hallux valgus, no osseous erosion on either side, bilateral distal Achilles enthesopathy, apparent flatfeet, and no radiopaque foreign body. In support of her claim, in October 2019, the Veteran submitted a medical opinion by Dr. Miller who found that it was at least as likely as not that her bilateral hallux valgus/bunion deformities were the direct result of wearing combat boots that were too narrow for her feet during her time on active duty. Dr. Miller noted that the wearing combat boots during AIT that were too narrow aggravated the natural progression of each condition. The Board notes that Dr. Miller's evaluation was not based on an in-person examination but rather a "personal Clinical interview" with the Veteran and claims file review. Yet, this private physician, without observing the Veteran's feet, provides an etiology opinion. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Unfortunately, Dr. Miller does not address the evidence of record which shows no aggravation of the Veteran's preexisting hallux valgus deformity and an alternative etiology including a January 2012 x-ray of the Veteran's feet showing only mild bilateral hallux valgus deformity; a November 2012 opinion by a podiatrist indicating that the Veteran's hallux valgus deformity was related to foot pronation and first ray hypermobility and elevated IM angle; and an August 2015 x-ray showing only slight interval progression of bilateral hallux. As such, it is the Board's opinion that an additional etiology opinion should be obtained with respect to the Veteran's foot pain only after physical examination of the Veteran and a thorough review of the claims file. Entitlement to service connection for an acquired psychiatric disability, to include PTSD Report of Medical Examination in May 2007 for enlistment into the National Guard indicated clinical evaluation of the Veteran's psychiatric health to be normal. On the Report of Medical History completed by the Veteran in conjunction with her enlistment physical, she denied ever having nervous trouble of any sort (anxiety or panic attacks), frequent trouble sleeping, and depression or excessive worry. She also denied ever having been evaluated or treated for a mental condition. The record includes police incident reports. A June 2007 incident report notes that the Veteran stated that she believed if she left her house, people who were hanging out on her block and belonged to a gang would kill her. A July 2007 incident report notes that the Veteran reported being stalked by a gang but was unable to provide names of possibly involved parties and could not describe incident of stalking. A June 2008 incident report notes that the Veteran believed that her old neighbor was following her everywhere but would not give any further information. As noted above, the August 2009 Inspector General Action Request requested support with stalking and false entrapment by stalkers. In October 2009, the State Inspector General responded that his office had had received the Veteran's letter to the Inspector General concerning rank reduction, drill pay, and BAH entitlements; that his office would initiate an inquiry into the matter presented; and that she would be advise of the results at the conclusion of the inquiry. In September 2009, the Veteran provided a lengthy account of incidents that began in 2000 with a burglary in which items were taken which the Veteran believed were used to track and control her life, and which continued for eight years including subsequent automobile break-ins, harassment, intimidation, and stalking by alleged gang members even though the Veteran moved residences. The Veteran related that as she needed a job where she would be safe, she joined the National Guard; however, on her way to basic training and AIT, the tracking and stalking began again. The Veteran related that it was towards the end of basic training when she realized that her stalkers had connections within the military, and the stalking continued. In September 2009, the Veteran was seen by her primary care physician and reported that she had been seeing a therapist for a month and a half for depression. The Veteran noted that she was being stalked by a gang and had nightmares. The Veteran reported that she had been diagnosed as having PTSD. A September 2009 letter authored by the Veteran's psychotherapist and a licensed clinical supervisor indicates that she began weekly therapy sessions in August 2009. Later that month, the Veteran underwent a psychiatric intake evaluation at which time she reported an unclear history of being stalked since the year 2000 at which time she was living in a poor neighborhood with high crime rates. The Veteran stated that her apartment was burglarized and that two days later a member of a gang came back to the house stating that he had 'gotten them' (indicating that it was their gang that burglarized the house). The Veteran stated that ever since that incident, the same neighbor and his gang had been stalking her and that she believed that they started stalking her with the intent to use her in a "human trafficking" racket that they were operating. The Veteran stated she was had been followed by members of that gang to her place of business where they made it known that they were following her and that they had placed tracking devices on her car and were using computers to track her. The Veteran reported that she felt traumatized by this nine-year history of being stalked. The Veteran reported that she joined the National Guard in part because she thought that it would help her feel safer from the stalkers; and while it did enable her to become less isolated and venture out of the house, she was disturbed to learn that the gang members belonged to the military and they continued to stalk her even in the National Guard. The Veteran reported that her first mental health encounter was less than two months prior when she engaged in psychotherapy meeting once weekly initially and decreased the frequency to once every other week due to financial constraints. Diagnoses included rule out psychotic disorder, rule out PTSD, and rule out malingering. In a letter addressed to Whom it May Concern, the Veteran's therapist noted that based on the evaluation, she believed it was unsafe for the Veteran to handle firearms. In October 2009, the Veteran underwent telephone consultation and noted that one of her stalkers had been apprehended. The telephone call was interrupted, and the therapist was unable to reach the Veteran again. Diagnostic impression indicated that the Veteran was most likely suffering from a severe, untreated delusional disorder; that it was impossible to fully assess veracity of alleged events with associated PTSD; and that a diagnosis of malingering to be excused from military activities could also be a possibility, although much less likely. In November 2009, the Veteran's diagnoses were changed to psychotic disorder, rule out PTSD, and rule out malingering. In February 2010, a psychologist recommended more extensive neuropsychiatric evaluation to rule out possible psychotic/delusional disorder and treatment for depression. The psychologist noted that the Veteran was deemed undeployable at that time and was not recommended for active duty or independent service without more assessment. That same month, the Veteran underwent VA psychiatric evaluation for retention in the National Guard. The psychologist noted that the Veteran reported that prior to joining the National Guard, she had been stalked and harassed by three men which had continued for three years. The Veteran stated that they had drawn weapons on her and used a tracking device on her car. She reported that she feared that they would draw weapons on her because they "might not approve of me." She referred to "false entrapment", and a "network of men." The psychologist noted that limited background material had been available for the evaluation, and it was recommended that a more formal neuropsychiatric evaluation be conducted. Initial clinical impression indicated psychotic thinking with a fixed paranoid delusional system as well as symptoms of major depression coincident with her being "stalked." The psychologist noted that pending further evaluation, it was deemed that the Veteran was not fit for active duty and should not carry firearms or work independently. The Veteran was placed on a physical profile for, inter alia, delusional psychosis with prior history of paranoia. A February 2010 National Guard Medical Determination indicates that the Veteran's delusional/psychotic processes required further evaluation per psychologist; referral to Medical Evaluation Board was recommended. In a Voluntary Witness Statement completed by the Veteran in April 2012, she related that she and her daughter had been victims of severe and pervasive stalking, harassment, sexual harassment, and false imprisonment with the suspects being both active and non-active military personnel. The Veteran was seen for VA biopsychosocial assessment in March 2012 at which time she reported that she joined the National Guard in 2006, that she was on active duty "a couple times" but did not serve in combat, and that "stalking" incidents began while she joined the Guard in 2006. The Veteran reported that she was followed and approached by "gang members" at Camp Roberts and in with her unit in Richmond and that similar incidents occurred while veteran was on a training in North Carolina. The Veteran reported that she was questioned about "sexual favors," and about her own gang affiliations. She reported that other people, including some of her friends, witnessed the harassment. She was diagnosed as having rule out PTSD, rule out delusional disorder, rule out anxiety disorder NOS. The clinician noted that he was waiting on collateral contact with the Veteran's psychiatrist to clarify clinical picture. In May 2012, the Veteran was seen for VA PTSD initial assessment at which time she was diagnosed as having rule out delusional disorder, rule out anxiety disorder NOS. In June 2012, the Veteran was seen for possible rerating for her fibroid related issues including emotional response component. In a September 2012 letter, a private physician indicated that the Veteran presented in August 2010 with a past medical history of PTSD and affective disorder which she dated back to when she was on active duty. The physician noted that the Veteran described that during her basic training she experienced anxiety due to abusive behavior from members in her unit which involved stalking behavior and other forms of intimidation and harassment and which were not properly addressed by the chain of command which worsened her anxiety and depression. The physician opined that the PTSD, depression, and affective disorder were associated with events while the Veteran was on active duty. In October 2012, VA clinical psychologist noted that an assessment needed to be accomplished to include completing CAPS (clinician Administered PTSD scale) on trauma's relayed (1) home invasion in 2000 (2) being targeted and "a victim of false imprisonment" from 2000 to 2006 by gang members, and (3) being harassed in the military by gang affiliates involved with home invasion of 2000. In November 2012, the Veteran underwent VA mental health PTSD intake assessment at which time she related 2000 home invasion and subsequent incidents of following, threatening, keeping her isolated, regulating her movements by GPS, and propositioning her for sexual acts even after joining the National Guard. After interview with the Veteran and mental status examination, the Veteran was diagnosed as having rule out delusional disorder and rule out PTSD. The provider assessed that based on information, symptoms onset began following home invasion. In December 2012, CAPS was administered which revealed that the Veteran believed that events similar to past trauma were continuing to occur; the clinical psychologist noted that although 2000 home invasion and post-home invasion history were plausible, as the interview continued, it became clinically apparent that "this was more delusional in nature." In support of her claim, the Veteran submitted an October 22, 2011, article from Business Insider entitled, "The FBI Announces Gangs Have Infiltrated Every Branch of the Military." The Veteran wrote to her representative in Congress requesting a written statement from her former commander with the California Army National Regard regarding her incident that occurred between 2008 and 2009. In March 2014, the Congresswoman responded that she contacted both the Department of Defense National Guard Bureau and the Military Department's Office of the Adjutant General in order to request that they provide you with any available information. The Congresswoman noted that her office received a response from the Military Department stated that it conducted a review and spoke to the Veteran's former commander; however, although the commander vaguely remembered the Veteran, she was unable to recall the details of the incident referenced and did not have any documentation to reference. In July 2014, the Veteran's brother submitted a lay statement that during the summer of 2008, he was a passenger in the Veteran's vehicle when he noticed a vehicle following for at least five miles. The Veteran's daughter also submitted a statement that she had been with her mother on a few occasions when she experienced suspicious activity followed by aggravated stalking and that she herself had been followed by suspicious men. It does not appear that all treatment records have been associated with the file. The record indicates that the Veteran was seen by outside psychiatrists, Dr. David Cohn and Dr. Dickey whose medical records have not been requested. Further, it is the Board's opinion that an etiology opinion should be obtained with respect to the Veteran's psychiatric disorders after examination of the Veteran and a thorough review of the claims file. Entitlement to service connection for a thoracolumbar spine (back) disability X-ray of the lumbar spine in September 2012 was negative; x-ray of the thoracic spine in December 2013 identified osteoarthritis mid thoracic spine; and x-ray in February 2014 demonstrated mild multilevel lumbar spondylosis with no acute fracture of subluxation. The Veteran underwent VA examination in June 2015 at which time the examiner found that he had never been diagnosed as having a thoracolumbar spine condition. On physical examination, the Veteran demonstrated diminished forward flexion. The examiner noted that the Veteran's physiologic age, and body mass index (BMI) of 37, it was understandable that her lumbar condition was regression of her condition. The examiner noted that she was more symptomatic considering in comparison than the service-connected right knee strain, that her radiographic study was normal, and that the lumbar condition was neither aggravated nor secondarily caused by her right knee strain. In support of her claim, in October 2019, the Veteran submitted a medical opinion by Dr. Miller who found that it was at least as likely as not that the Veteran's thoracolumbar spine, chronic mechanical low back syndrome, was the direct result of her activities/injury sustained during AIT while on active duty in the United States Army. As noted above, Dr. Miller's evaluation was not based on an in-person examination but rather a "personal Clinical interview" with the Veteran and claims file review. Yet, this private physician, without observing the Veteran's spine, provides a diagnosis and an etiology opinion. Unfortunately, Dr. Miller noted that the Veteran began experiencing back pain during AIT and that she was given a profile that limited the amount of weight that she would have to carry in her rucksack. However, there is no specific complaint of back pain in the service treatment records. As such, it is the Board's opinion that an additional etiology opinion should be obtained with respect to the Veteran's thoracolumbar spine pain only after physical examination of the Veteran and a thorough review of the claims file. Entitlement to service connection for a left knee disability A December 2007 Fort Jackson Sick Slip indicates that the Veteran had complaint of edema to extremities; marching and wearing a ruck sack for more than 15 minutes was prohibited for not more than 30 days. In February 2008, the Veteran reported that her knees had been hurting since she started AIT because she was getting more exercise; specifically she noted pain in the knees, more on the right especially when running. She was diagnosed as having joint pain localized in the knee and overuse syndrome and was placed on a profile from February 28, 2008 to March 13, 2008 which was extended to March 26, 2008. In April 2008, the Veteran reported that her right knee was getting better with pacing her activities. A February 2008 Fort Jackson Sick Slip indicates that the Veteran was seen for muscle tension, swelling, and joint tenderness; the Veteran was returned to full duty and told to run with company once a week. A March 2008 Fort Jackson Sick Slip indicates that the Veteran had complaint of discomfort of muscle and joint follow up; running was prohibited for not more than 30 days. The Veteran underwent VA examination in January 2011 at which time she reported that she injured her knees from wearing her vest while in training. X-rays of the knees showed calcifications of the soft tissues superficial to bilateral patella, likely related to chronic repetitive inflammatory process and mild degenerative changes of the knees, right greater than left. The examiner diagnosed the Veteran with bilateral knee strain and opined that left knee strain was not caused by or a result of service. X-ray in December 2013 demonstrated calcifications of the soft tissues superficial to bilateral patella likely related to chronic repetitive inflammatory process and mild degenerative changes of the knees, right greater than left. X-ray of the left knee in December 2015 showed minimal to mild tricompartmental osteoarthritis. In support of her claim, in October 2019, the Veteran submitted a medical opinion by Dr. Miller who found that it was at least as likely as not that the Veteran's left knee condition, chondromalacia, was the direct result of an overuse syndrome involving the patellofemoral surfaces of the knee. As noted above, Dr. Miller's evaluation was not based on an in-person examination but rather a "personal Clinical interview" with the Veteran and claims file review. Yet, this private physician, without observing the Veteran's left knee, provides a diagnosis and an etiology opinion. As such, it is the Board's opinion that an additional etiology opinion should be obtained with respect to the Veteran's left knee pain only after physical examination of the Veteran and a thorough review of the claims file. Entitlement to an initial rating in excess of 10 percent for right knee strain At the VA examination in December 2010, flexion was limited to 100 degrees with normal extension. There was an absence of pain, weakness, fatigability, incoordination, and instability. At the June 2015 VA examination, flexion was limited to 90 degrees with normal extension and no joint instability. As it has been a number of years since the last VA examinations and a review of the evidence shows that the condition may have worsened since the 2015 VA examination report, a new examination is warranted. See, e.g., Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Thus, the Veteran should be scheduled to undergo a current VA examination to determine the current severity of his disability. Entitlement to a TDIU Finally, because decisions on the remanded issues could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. As such, a remand of the issue of entitlement to a TDIU is required. The matters are REMANDED for the following action: 1. Obtain the Veteran's complete service personnel records, to include all documents pertaining to her service in the California Army National Guard. Verify all inactive duty training dates for service in the California Army National Guard from December 2008 to June 2009. If necessary, a request should be made to the Defense Finance and Accounting Service (DFAS). Document all requests for information as well as all responses in the claims file. 2. Obtain the Veteran's federal records from SSA. Document all requests for information as well as all responses in the claims file. 3. Ask the Veteran to complete a VA Form 21-4142 for Dr. David Cohn and Dr. Jan V. Dickey. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 4. Schedule the Veteran for a VA psychiatric examination, preferably with either a psychiatrist or a psychologist, to address the nature and etiology of any psychiatric disability, to include PTSD. The examiner must review the claims file. The examiner must identify all current, chronic psychiatric diagnoses. If the Veteran is diagnosed with PTSD, the examiner must (i) explain how the diagnostic criteria are met and (ii) opine whether the evidence of record, including the Veteran's lay statements, lay statements made by the Veteran's brother, daughter, and friend (BH), and the Veteran's service records, corroborate the claim that she suffered events allegedly perpetrated by gang members during her active duty for training period from November 2007 to May 2008 (38 C.F.R. § 3.304(f)(5)). For all chronic psychiatric diagnoses; or, with respect to PTSD, if the evidence indicates that alleged events occurred during the Veteran's active duty for training period; the examiner should provide an opinion as to whether there is clear and unmistakable evidence (evidence that is obvious and manifest) that PTSD or any other diagnosed psychiatric disorder (i) existed prior to service; and if so, (ii) did not increase in severity during the Veteran's active duty for training period or was "due to the natural progression" of the disease. Please note that temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. In addition, a condition that worsened during service and then improved due to in-service treatment to the point that it was no more disabling than it was at induction is analogous to a condition that has flared up temporarily. If PTSD or any other diagnosed psychiatric disorder did not exist prior to service, did not increase in severity during the Veteran's active duty for training period, or was "due to the natural progression" of the disease, the examiner must address whether an identified psychiatric disorder is at least as likely as not a. related to the Veteran's active duty for training period; b. proximately due to service-connected right knee strain or menorrhagia/fibroid uterus; c. aggravated, i.e., worsened beyond its natural progression, by service-connected right knee strain or menorrhagia/fibroid uterus? 5. Schedule the Veteran for a VA foot examination, preferably with a podiatrist, to determine the nature and etiology of any current, chronic foot disorder, including hallux valgus/bunions. The examiner must review the claims file including the September 29, 2019, medical evaluation report by Dr. Donald Miller, Jr. The examiner must identify all current, chronic foot diagnoses. The examiner should provide an opinion as to whether the Veteran's hallux valgus, which existed prior to service, at least as likely as not increased in severity during a period of active duty for training or inactive duty training. If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to aggravation by the service-connected disability. Please note that temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. In addition, a condition that worsened during service and then improved due to in-service treatment to the point that it was no more disabling than it was at induction is analogous to a condition that has flared up temporarily. For any other foot disorder, the examiner should provide an opinion as to whether such foot disorder is at least as likely as not related to the Veteran's active duty for training period or any period of inactive duty training. 6. Schedule the Veteran for a VA knee examination, preferably with an orthopedist, to address (i) the severity of right knee disorder and (ii) the nature and etiology of any current, chronic left knee disorder. The examiner must review the claims file including the June 10, 2015, VA Knee and Lower Leg Conditions Disability Benefits Questionnaire and the September 29, 2019, medical evaluation report by Dr. Donald Miller, Jr. The examiner must provide a full description of the Veteran's right knee disability and report all signs and symptoms necessary for evaluating the Veteran's right knee disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. The examiner must identify all current, chronic left knee diagnoses and provide an opinion as to whether such left knee disorder is at least as likely as not related to the Veteran's active duty for training period or any period of inactive duty training. 7. Schedule the Veteran for a VA thoracolumbar spine examination to address the nature and etiology of any current, chronic thoracolumbar spine disorder. The examiner must review the claims file including the June 10, 2015, VA Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire and the September 29, 2019, medical evaluation report by Dr. Donald Miller, Jr. The examiner must identify all current, chronic thoracolumbar spine diagnoses and provide an opinion as to whether such thoracolumbar spine disorder is at least as likely as not related to the Veteran's active duty for training period or any period of inactive duty training. 8. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to a TDIU. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. J. Dworkin Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.