Citation Nr: 21006129 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 17-30 158 DATE: February 3, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety, is granted. Entitlement to service connection for an acquired psychiatric disorder is granted. Entitlement to service connection for sleep apnea is denied. REMANDED Entitlement to a rating in excess of 10 percent for a right ankle disability is remanded. Entitlement to service connection for a gastrointestinal disability is remanded. Entitlement to service connection for a menstrual disorder, to include hysterectomy, is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for plantar fasciitis is remanded. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. In a July 2016 rating decision, the RO denied the Veteran’s claim of service connection for PTSD, depression, stress disorder, and bipolar disorder. Although she was duly notified of the RO’s decision and her appellate rights, the Veteran did not initiate an appeal within the applicable time period nor was new and material evidence received within one year. 2. Evidence received since the final July 2016 rating decision denying entitlement to service connection for PTSD, depression, stress disorder, and bipolar disorder relates to an unestablished fact necessary to substantiate the claim and, presuming its credibility, raises a reasonable possibility of substantiating the claim for service connection for an acquired psychiatric disorder. 3. The evidence is at least in equipoise as to whether the Veteran’s currently diagnosed acquired psychiatric disorder was incurred in her active military service. 4. The most probative evidence establishes that the Veteran does not have sleep apnea which was incurred in or was otherwise causally related to her active military service. CONCLUSIONS OF LAW 1. The July 2016 rating decision denying service connection for PTSD, depression, stress disorder, and bipolar disorder is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. New and material evidence has been received to warrant reopening of the claim of service connection for an acquired psychiatric disorder. 38 U.S.C. § 5107, 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for entitlement to service connection for sleep apnea have not 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 from July 2008 to July 2012, including service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from May 2014 and December 2018 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, denied service connection for a gastrointestinal disability, menstrual disorder, painful joints, plantar fasciitis, anxiety, and sleep apnea, continued the denial of service connection for PTSD because the evidence submitted was not new and material, and continued the 10 percent rating for the Veteran’s service-connected right ankle disability, respectively. The Board notes that the Veteran’s July 2014 Notice of Disagreement (NOD) also included the issues of entitlement to service connection for a heart disability, head injury, hearing loss, left wrist condition, vaginal condition, residuals of surgery, osteoarthritis, and non-specific orthopedic claims. In a March 2017 rating decision, the RO granted service connection for a right ankle disability, with residual degenerative joint disease, and a left wrist disability and assigned each a 10 percent rating, effective September 8, 2013. Additionally, the RO deferred the issue of service connection for a head injury. The remainder of the issues were included in the March 2017 Statement of the Case (SOC). As the Veteran’s June 2017 VA Form 9 indicated that she wished to limit her appeal to the issues of entitlement to service connection for a gastrointestinal disability, menstrual disorder, painful joints, and plantar fasciitis, the issues of entitlement to service connection for a heart disability, hearing loss, vaginal condition, residuals of surgery, and non-specific orthopedic claims are not before the Board on appeal. As the claim of service connection for a head injury has not yet been addressed by the RO and is therefore not before the Board at this time. The Board also notes that in her June 2017 VA Form 9, the Veteran requested a hearing with respect to the issues of entitlement to service connection for a gastrointestinal disability, a menstrual disorder, painful joints, and plantar fasciitis. In September 2020 correspondence, the Veteran, through her attorney, withdrew her request for a hearing. Accordingly, the Board deems the hearing request withdrawn. 38 C.F.R. § 20.704(e). In light of the Veteran’s contentions and the evidence of record, the Board has recharacterized the Veteran’s claims of service connection for PTSD and anxiety more broadly as a claim of service connection for an acquired psychiatric disorder, to include PTSD and anxiety. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that VA must construe a claim for service connection to include any disability that may reasonably be encompassed by the claimant’s description of the claim, the symptoms the claimant describes, and the information the claimant submits or that the Secretary obtains in support of the claim). Given the Veteran’s contentions and the evidence of record, the Board has also recharacterized the Veteran’s claim of service connection for painful joints as a claim of service connection for a right knee disability. In light of the decision and remand below, no prejudice to the Veteran has resulted from the Board’s recharacterization of the issues. Bernard v. Brown, 4 Vet. App. 384 (1993) (holding that before the Board may address a matter that has not been addressed by the RO, it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument, an opportunity to submit such evidence or argument, and an opportunity to address the question at a hearing, and whether the claimant has been prejudiced by any denials of those opportunities). The Board notes that after the appeal was certified and transferred to the Board, the Veteran submitted additional evidence, to include a private medical opinion, which was associated with the Veteran’s electronic claims file. Since the Veteran has waived RO consideration, agency of original jurisdiction (AOJ) review is not required. New and Material Evidence 1. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disorder is granted. In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. See 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims to reopen such as this one, filed on or after August 29, 2001, 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. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). 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, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Id. at 118; but see Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). In January 2016, the Veteran submitted a claim of service connection for PTSD, depression, stress disorder, and bipolar disorder. In a final July 2016 rating decision, the RO denied the claim, finding that the evidence did not show a currently diagnosed disability or that the alleged condition was incurred in or caused by service. The RO considered the Veteran’s service treatment records (STRs), which were negative for complaints, treatment, or diagnosis of a psychiatric disability. Additionally, the RO noted that the available medical evidence was insufficient to confirm a link between the Veteran’s current symptoms and an in-service stressor. The record on appeal shows that the Veteran was duly notified of the RO’s decision and her appellate rights. She did not, however, initiate an appeal within the applicable time period nor was new and material evidence received within one year of notification of the July 2016 rating decision. The Veteran does not contend otherwise. Thus, the July 2016 rating decision is final and not subject to revision on the same factual basis. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. In this appeal, the Veteran seeks to reopen her claim of service connection for an acquired psychiatric disorder. As noted above, despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. In order to determine whether new and material evidence has been received, the Board has reviewed the entire record, with particular attention to the additional evidence received since the final July 2016 rating decision. After reviewing the record, the Board finds that the additional evidence received is new and material within the meaning of 38 C.F.R. § 3.156. The additional evidence received since the July 2016 rating decision includes VA treatment records noting diagnoses of anxiety disorder, insomnia, major depressive disorder, cannabis use, and reaction to severe stress. See February 2019 Mental Health Note. The additional evidence also includes statements from the Veteran and her partner, J.B., to the effect that the Veteran did not experience mental health problems prior to active duty. However, following her return from service, the Veteran experienced psychiatric symptoms, to include anger, hypervigilance, nightmares, anxiety, and depression. See June 2020 Affidavits from the Veteran and J.B. received September 2020. Also received since the July 2016 rating decision is a private psychological evaluation noting a diagnosis of PTSD, as well as panic disorder, and linking such to the Veteran’s active duty. See August 2020 Psychological Evaluation from E.Z., Psy.D., QME. After reviewing the record, the Board finds that new and material evidence has been received sufficient to reopen the claim. Specifically, the VA treatment records noting diagnoses of anxiety disorder, insomnia, major depressive disorder, cannabis use, and reaction to severe stress, as well as the August 2020 private psychological evaluation noting diagnoses of PTSD and panic disorder and linking such to the Veteran’s active duty, were not before agency decision-makers at the time of the July 2016 rating decision. These records are therefore new, and directly address unestablished facts necessary to substantiate the claim of service connection for an acquired psychiatric disorder, particularly evidence of a current disability and causation. When presumed credible, they raise a reasonable possibility of substantiating the claim and trigger the VA’s duty to assist. Accordingly, the standards under 3.156(a) have been met and the claim is reopened. See Shade, 24 Vet. App. at 117. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain specifically enumerated chronic diseases, including psychoses, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for an acquired psychiatric disorder is granted. The Veteran contends that her acquired psychiatric disorder is due to her active service. The Veteran’s service treatment records (STRs) are silent for complaints, observation, or treatment regarding a psychiatric disability. In a January 2016 stressor statement, the Veteran reported that while she was deployed to Bahrain, Bahraini natives frequently protested and rioted outside the gates of the airport at which she worked. She reported that police in riot gear were always there to attempt to contain the crowd. The Veteran reported that the natives often threw rocks, pipes, and any other materials they could find at the van which transported her and her fellow servicemembers to and from the airport. She reported that one night, a civilian rushed toward them as they were leaving the airport, and he was shot in from of them. She stated that as a result, she felt unsafe for the rest of her time in Bahrain. See January 2016 VA 21-0781 Statement in Support of Claim for PTSD. The Veteran was afforded a VA examination in July 2016. The examiner noted the Veteran’s reports of sleep problems and “feeling pretty down on [her]self.” As to the Veteran’s claimed stressor, the examiner noted the Veteran’s reports that during her service in Bahrain, she was fearful of the Bahraini nationalists who attempted to hurl pipes and large rocks at the van which transported the Veteran and fellow servicemembers to the airport at which they worked. She also reported that the nationalists threw a teargas cannister over the base. After examination of the Veteran and review of the claims file, the examiner determined that the Veteran did not have a diagnosis of PTSD or any other mental health disorder. The examiner noted that the Veteran’s self-report was found to be of questionable validity for diagnostic and rating purposes. Additionally, the examiner noted that it appeared that the Veteran had not received mental health treatment either during service or since discharge to review and glean supporting information relating to possible emotional difficulties. A February 2019 VA treatment record noted the Veteran’s reports of anxiety, hypervigilance, avoidant behavior, irritability, and depression. The Veteran reported that she worked at an airport in Bahrain during active duty where she would often see citizens in the community rioting. She reported watching them throw rocks at the van in which she traveled to and from the airport. The Veteran reported feeling a “looming threat,” which was very stressful for her. Also noted were diagnoses of anxiety disorder, insomnia, major depressive disorder, cannabis use, and reaction to severe stress. See February 2019 Mental Health Note. In a May 2019 VA treatment record, the Veteran reported that she felt generally “unhappy” since her discharge from the military in 2012. See May 2019 Neuropsych Testing Consult. In correspondence dated in June 2020, the Veteran indicated that in August 2011 an angry civilian rushed toward her as she was leaving the airport in Bahrain and was shot and killed in front of her. She indicated that she did not know from where the shot came, however, she was scarred from the fear and terror she felt. She also indicated that she did not experience mental health problems prior to active duty. However, following her return from service, she experienced psychiatric symptoms, to include anger, hypervigilance, nightmares, anxiety, and depression. See June 2020 Affidavit from the Veteran; see also June 2020 Affidavit from J.B. received September 2020. In an August 2020 psychological evaluation, a private psychologist, Dr. E.Z., indicated that the Veteran had diagnoses of PTSD, panic disorder, and alcohol and cannabis use disorders. The psychologist indicated that it was not possible to differentiate the specific symptoms and functional impairment caused by each disorder. As to the Veteran’s claimed stressor, Dr. E.Z. noted the Veteran’s reports of witnessing the shooting death of a Bahraini nationalist during active duty. The Veteran also reported witnessing protestors as she traveled to and from work while she was deployed to Bahrain. After examination of the Veteran and review of the claims file, the psychologist opined that the Veteran’s psychiatric disorder was at least as likely as not caused by events during the Veteran’s service in Southwest Asia. After a review of the record, the Board has determined that the evidence of record is at least in equipoise as to whether the Veteran’s current acquired psychiatric disorder was incurred during her military service. With respect to the Veteran’s reported in-service stressor, the Board finds no adequate basis to reject the competent lay statements and medical evidence of record that is favorable to the Veteran, based on a rational lack of credibility or probative value. See Madden v. Gober, 125 F.3d 1477, 1481 (1997) (in evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole); see also Evans v. West, 12 Vet. App. 22, 26 (1998). The evidence is not unequivocal; however, the Board nevertheless finds that the evidence is at least in equipoise with respect to the question of a corroborated stressor. Notably, the circumstantial evidence of record tends to corroborate the reported stressor; in particular, the Veteran’s documented service in Southwest Asia. Her personnel records reflect that while stationed in Bahrain, her duties included procurement of aeronautical components and materials in support of aircraft. Moreover, as noted above, the post-service clinical evidence of record demonstrates the Veteran’s emotional decline following her return from Southwest Asia. In sum, the Board therefore finds that the in-service stressor identified by the Veteran has been corroborated. See 38 C.F.R. § 3.304(f). The Board further finds that this satisfies the criteria of an in-service injury under 38 C.F.R. § 3.303. Regarding whether the Veteran has a current acquired psychiatric disorder, or has PTSD diagnosed in accordance with 38 C.F.R. § 4.125, the Board notes the Veteran has been diagnosed with various mental health conditions during the course of this claim, to include anxiety and panic disorders, major depressive disorder, alcohol and cannabis use disorders, and PTSD. Based on the evidence of record, it is difficult to make a finding as to the Veteran’s current diagnosis because the medical professionals who have offered opinions in this case, as well as treating physicians, appear to be in disagreement as to the current diagnosis. Regardless, what is clear is that the Veteran does currently have an acquired psychiatric disability with active symptomatology. As such, the Board finds that the preponderance of the evidence establishes the Veteran does have a current acquired psychiatric disability, regardless of the label it is assigned. 38 C.F.R. §§ 3.303(a). The question before the Board then, is whether there is a link between the Veteran’s current acquired psychiatric disability and the above discussed stressor. Considering all the evidence of record, the Board finds the evidence is at least in equipoise on the question of whether the Veteran’s current acquired psychiatric disorder or disorders are at least as likely as not related to her active service, including experiencing protestors throwing objects at her vehicle on a frequent basis. In that regard, the Board assigns great probative weight to the August 2020 psychological evaluation in which Dr. E.Z. opined that the Veteran’s acquired psychiatric disorder was at least as likely as not caused by events during the Veteran’s service in Southwest Asia. The opinion provides an adequate and probative rationale for its conclusion. The Board assigns less probative weight to the July 2016 VA examination, as the examiner found that the Veteran did not have a psychiatric disability, to include PTSD, in part, because the Veteran failed to seek mental health treatment during and after active duty. As the evidence is in equipoise, the Board grants the Veteran the benefit of the doubt, and finds it is at least as likely as not she has an acquired psychiatric disorder that is at least as likely as not related to her in-service stressor. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the Board concludes that the criteria for entitlement to service connection for an acquired psychiatric disorder have been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 3. Entitlement to service connection for sleep apnea is denied. The Veteran seeks service connection for sleep apnea, with no specific contentions alleged. The Veteran’s STRs do not document any sleep-related abnormalities or complaints. An August 2017 sleep study impression report was negative for obstructive sleep apnea. See August 2017 Pulmonary Sleep Study Report Consult. An April 2019 VA treatment record noted that the Veteran had been prescribed Mirtazapine for insomnia. See April 2019 Primary Care Note. In correspondence dated in June 2020, the Veteran and her partner, J.B., indicated that the Veteran experienced nightmares and sleep disturbances upon her return from active duty. See June 2020 correspondence from the Veteran and J.B., received September 2020. Based on the foregoing record, the Board finds that the most probative evidence establishes that the Veteran does not currently have sleep apnea, either diagnosed pathology or functional impairment. Post-service clinical records contain no indication that the Veteran has been treated for or diagnosed with sleep apnea. Notably, the August 2017 sleep study impression report, noted above, was negative for obstructive sleep apnea. Although the Board notes that the Veteran experiences sleep-related symptomatology, to include insomnia, this symptom will be considered in the assigned rating for her acquired psychiatric disorder which was granted in the instant decision. The Board notes that “disability” as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability. In this case, however, there is no competent evidence tending to show that the Veteran has additional sleep impairment which rises to a level to affect earning capacity. She has not shown or specifically alleged that she has manifestations of similar severity, frequency, and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, No. 18-4349 (U.S. Vet. App. August 26, 2020). While the Veteran has claimed that she has sleep apnea, as a lay person she is not competent to provide such a diagnosis. Moreover, as set forth above, the clinical evidence affirmatively established that she does not have sleep apnea and the Board assigns more probative weight to the objective clinical evidence than to the Veteran’s lay statements. Simply, there is no diagnosed disability, separate from chronic sleep impairment, which will be contemplated in the assigned rating for her service-connected acquired psychiatric disorder, which was granted in the instant decision; and there is no indication that the Veteran’s condition reached the level of a functional impairment of earning capacity. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. Based on the foregoing, as the probative evidence is against the Veteran’s claim for service connection for sleep apnea, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran’s claim for sleep apnea is denied. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for a right ankle disability is remanded. The Veteran contends that her right ankle disability is more severe than currently rated. The Veteran was most recently afforded a VA examination in December 2018. The VA examination was not conducted during a flare-up. The examiner noted the Veteran’s reports of flare-ups, which she described as “intense aching that keeps me inside” and “super stiff and hard to move.” The examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss during flare-ups but indicated that she could not say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups. She stated, [This] would require an examination during an acute flareup to determine the impact on functional ability as an increase in the intensity of pain is a characteristic feature of the flare-up. The examiner did not provide a range of motion (ROM) assessment of the Veteran’s flare-ups. The United States Court of Appeals for Veterans Claims (Court) held in Sharp v. Shulkin, 29 Vet. App. 26 (2017), that, pursuant to VA regulations and the VA Clinician’s Guide, when conducting evaluations for musculoskeletal disabilities, VA examiners are obligated to inquire whether there are periods of flare-ups and, if so, to state their “severity, frequency, and duration; name the precipitating and alleviating factors; and estimate, ‘per [the] veteran,’ to what extent, if any, they affect functional impairment.” Id. at 32. The Court further explained that, in the event an examination is not conducted during a flare-up, the ”critical question” in assessing the adequacy of the examination was “whether the examiner was sufficiently informed of and conveyed any additional or increased symptoms and limitations experienced during flares.” Id. at 34 (quoting Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011)). Moreover, these rules are applicable to musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the diagnostic code under which the disability is being evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). Consequently, the Board finds that the examiner did not adequately address the Veteran’s functional loss during flare-ups. Essentially, the examiner reported an inability to describe functional loss during flare-ups in terms of additional range of motion loss was not possible because the examination was not conducted during a flare-up. As the evidence of record suggests that flare-ups are of a limited duration, it does not appear feasible to examine the Veteran during a flare-up. Rather, the examiner should elicit all necessary information from the Veteran during the examination, including severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, in order to offer an opinion on flare-up functional loss in terms of range of motion. In light of the above deficiencies, the Board finds that a remand is necessary in order to obtain another VA examination that adequately addresses the current severity of the Veteran’s right ankle disability. 2. Entitlement to service connection for a gastrointestinal disability is remanded. The Veteran contends that she developed gastrointestinal symptoms during her deployment to Bahrain. She asserts that she did not have access to non-emergency medical care during that time and often self-medicated. See August 2018 Transcript of DRO Hearing, pages 17-20. The Veteran’s STRs are silent for complaints, observations, or treatment regarding a gastrointestinal disability. The Veteran was afforded a VA examination in July 2016. The examiner noted a 2015 diagnosis of gastrointestinal reflux disease (GERD). The Veteran reported that her gastrointestinal symptoms began in approximately December 2011, at which time she began taking TUMS. The Veteran reported that she was currently taking Omeprazole daily and that she did not have any symptoms. The examiner determined that GERD was not an undiagnosed or chronic multi-symptom illness, however, an opinion on direct service connection was not provided. The Board finds that the VA examination is inadequate, as the examiner failed to provide an etiological opinion regarding direct service connection. 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). As such, remand is required for a medical opinion to address the nature and etiology of the Veteran’s gastrointestinal disability. 3. Entitlement to service connection for a menstrual disorder, to include hysterectomy, is remanded. The Veteran contends that her current menstrual disorder, status post hysterectomy, is related to the heavy menstrual bleeding and severe cramping she experienced during active duty. See August 2018 Transcript of DRO Hearing, pages 21-30. The Veteran’s attorney argues that the Veteran’s menstrual disorder is a qualifying chronic disability, for which she should be service-connected due to her service in Southwest Asia. See September 2019 correspondence from the Veteran’s attorney. The Veteran’s STRs noted dysmenorrhea on the chronic problem list since at least December 2009. See December 24, 2009 Chronic Problems. An August 2018 VA treatment record noted the Veteran’s complaints of daily menstrual bleeding. It was noted that the Veteran “insists she wants a hysterectomy to stop the bleeding.” See August 2018 Gynecology Clinic Note. An October 2019 VA treatment record noted a history of secondary amenorrhea status post hysterectomy in October 2018. See October 2019 Primary Care Follow-Up. The VA has a duty to assist the Veteran in obtaining a medical examination or opinion in certain circumstances. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). A VA examination must be obtained in a disability compensation claim if there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; establishment of an in-service event, injury, or disease; an indication that the current disability may be associated with an in-service event or another service-connected disability; and insufficient competent medical evidence to make a decision on the claim. McClendon v. Nicholson, 20 Vet. App. 79, 81-6 (2006). In this case, the Veteran has not been afforded a VA examination in connection with her claim, and there is insufficient competent medical evidence to make a decision on the claim. As such, remand is warranted for a VA examination to determine whether the Veteran’s menstrual disorder was incurred in or is otherwise causally related to her active service, to include her service in Southwest Asia. 4. Entitlement to service connection for a right knee disability is remanded. The Veteran contends that she began experiencing right knee pain during active duty, which has continued to the present. She contends that she also currently experiences popping and grinding in her right knee, often with reduced mobility and flexibility. See August 2018 Transcript of DRO Hearing, pages 12 and 13. A June 2012 entry in the Veteran’s STRs noted that she was treated for a knee sprain. See June 2012 Physician’s Discharge Summary. The Veteran was afforded a VA examination in March 2017. The examiner noted a 2012 diagnosis of right knee strain. The Veteran reported that a retractable door hit her in the right knee during service, resulting in a knee strain. She reported that she did not have care at that time and continued to do regular PT. She also reported that she did not have care after service. The Veteran reported that she currently experienced knee pain with sitting too long 4 to 5 days per week, lasting for approximately 2 hours, which she rated as 7 on a 10-point scale. The Veteran also reported popping of the knees. The examiner noted that the Veteran had not been seen for her knee since separating from service. After examination of the Veteran and review of the claims file, the examiner rendered a negative etiological opinion regarding the Veteran’s right knee. The examiner opined, The veteran was seen on one occasion on 6/2/12 for c/o contusion and knee (doesn’t specify which knee) sprain treated with knee immobilizer, crutches and hydrocodone. This condition appears to [be] acute and transitory as she was not seen again with this diagnosis. The Veteran was noted to have an abrasion to the left knee in 7/3/10 post bicycle accident however again this appeared to be acute and transitory. There is no evidence since discharge in 2012 of c/o, diagnosis or treatment for a knee sprain in the current medical record. Physical exam noted slight limitation of ROM and crepitus however there is no confirmation of any knee condition by xray. The Board finds that the March 2017 VA examination is inadequate, as the examiner failed to address the Veteran’s reports of pain and difficulty sitting and whether those symptoms cause functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Additionally, subsequent to the VA examination, the Veteran testified that she had experienced knee pain since active duty and that her current symptoms included popping and grinding, as well as reduced mobility and flexibility. As such, remand is warranted for a new VA examination. 5. Entitlement to service connection for plantar fasciitis is remanded. The Veteran contends that her plantar fasciitis is secondary to her service-connected right ankle disability. See August 2018 Transcript of DRO Hearing, pages 3-7. An August 2017 VA treatment record noted the Veteran’s complaints of plantar and medial foot pain when standing for long periods. See August 8, 2017 Podiatry Clinic Consult. At the August 2018 DRO hearing, noted above, the Veteran testified that she experienced pain, numbness, and tingling in her feet. See August 2018 Transcript of DRO Hearing, pages 3-7. The Veteran was afforded a VA examination in March 2017. The examiner noted a 2008 diagnosis of pes planus and determined that such clearly and unmistakably pre-existed service and was not aggravated by service. The examiner, however, did not address the Veteran’s claimed plantar fasciitis. The Board finds that although the Veteran has been afforded a VA examination for her feet, the examiner failed to address whether she had a diagnosis of plantar fasciitis, and if so, whether such was causally related to active duty. As such, remand is warranted for a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303, (2007). 6. Entitlement to a TDIU is remanded. In correspondence dated in June 2020, the Veteran indicated that her psychiatric symptoms impacted her ability to work. Additionally, in the August 2020 psychological evaluation, Dr. E.Z. indicated that the Veteran was unable to secure substantially gainful employment due to her service-connected acquired psychiatric disorder. Thus, the Board finds that the record has reasonably raised the issue of entitlement to a TDIU. The Board notes that the AOJ has not had an opportunity to develop and adjudicate this issue in the first instance, to include providing the Veteran with the formal TDIU application form (VA Form 21-8940). Accordingly, the matters are REMANDED for the following action: 1. Develop the issue of entitlement to a TDIU, to include providing the Veteran with the formal TDIU application form (VA Form 21-8940). 2. Afford the Veteran a VA medical examination to evaluate the current severity of her service-connected right ankle disability. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the examination. The examiner should test for both active and passive motion, as well as weight-bearing and non-weight bearing. The examiner should comment on the severity of any painful motion or weakness. The examiner should also provide range of motion measurements, including at what point in the arc of motion pain limits function both regularly and during any flare-ups, even if a flare-up is not observed on that day. In addressing the nature of any disability during a flare-up the examiner must address the severity of the flare-up, the frequency and duration of the flare-up, and all precipitating and alleviating factors. 3. Obtain a VA medical opinion addressing the nature and etiology of the Veteran’s current gastrointestinal disability. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the opinion. After reviewing the record, provide an opinion, with supporting rationale, as to the following: Is it at least as likely as not that the Veteran’s current gastrointestinal disability had its inception during her period of active service or is otherwise causally related to an in-service disease or injury? In providing the requested opinion, the examiner should reference any relevant evidence of record, to include the Veteran’s August 2018 DRO hearing testimony indicating that she began to develop gastrointestinal symptoms during her deployment to Bahrain. In providing the requested opinion, the clinician should consider the Veteran’s reported symptoms in service and thereafter, including the onset, progression and severity of the Veteran’s reported symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran’s reports about her symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? 4. Afford the Veteran a VA medical examination addressing the nature and etiology of any current menstrual disorder, to include hysterectomy. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the examination. After examining the Veteran and reviewing the record, the examiner should provide an opinion, with supporting rationale, as to the following: (a) Is it at least as likely as not that any diagnosed menstrual disorder was incurred in or otherwise related to the Veteran’s active service? (b) If not, is it at least as likely as not that examination findings or other evidence demonstrate that any manifestations of the Veteran’s menstrual disorder represents an undiagnosed illness (where signs or symptoms cannot be attributed to known medical diagnoses) or a medically unexplained chronic multi-symptom illness related to her service in the Southwest Asia theater of operations? In providing the requested opinion, the examiner should reference any relevant evidence of record, to include the Veteran’s August 2018 DRO hearing testimony indicating that she developed heavy menstrual bleeding and severe cramping during active duty. 5. Afford the Veteran a VA medical examination addressing the nature and etiology of any current right knee disability. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the examination. After examining the Veteran and reviewing the record, the examiner should provide an opinion, with supporting rationale, as to the following: Is it at least as likely as not that any diagnosed right knee disability was incurred in or otherwise related to the Veteran’s active service? In providing the requested opinion, the examiner should reference any relevant evidence of record, to include the Veteran’s August 2018 DRO hearing testimony indicating that she has experienced right knee pain since active duty. 6. Afford the Veteran a VA medical examination addressing the nature and etiology of the Veteran’s claimed plantar fasciitis. Access to the Veteran’s electronic VA claims file must be made available to the examiner for review in connection with the examination. After examining the Veteran and reviewing the record, the examiner should provide an opinion, with supporting rationale, as to the following: Is it at least as likely as not that the Veteran’s claimed plantar fasciitis was incurred in or otherwise related to the Veteran’s active service? A complete explanation must be provided for any opinion offered. In providing the requested opinion, the examiner should reference any relevant evidence of record. 7. When the development requested has been completed, the case should be readjudicated by the AOJ, to include consideration of TDIU. If any benefit sought is not granted in full, the Veteran and her attorney should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ruddy, 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.