Citation Nr: 1333337 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 10-05 303 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for degenerative disc disease of the cervical and lumbar spine, to include as secondary to service-connected psoriasis and shell fragment wound muscle injury. 2. Entitlement to service connection for a bilateral hip disability, to include as secondary to service-connected psoriasis. REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1967. The appellant is the Veteran's surviving spouse and is pursuing this appeal as a substitute claimant under the provisions of 38 U.S.C.A. § 5121A (West 2002 & Supp. 2012). These matters initially came before the Board of Veterans' Appeals (Board) on appeal from February and June 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran died in December 2012, during the pendency of his appeal for the disabilities claimed herein. Accordingly, the Board dismissed the case in January 2013. Thereafter, the Veteran's surviving spouse and now appellant in this case filed timely filed a request for substitution. In May 2013, the RO determined that she is a valid substitute claimant and notified her of such. See VA Fast Letter (FL) 10-30 (issued August 2010, as revised April 2013); 38 U.S.C.A. § 5121A. Thereafter, the RO transferred the claims file to the Board for appellate consideration. See Veterans' Benefits Improvement Act of 2008, Pub. L. No. 110-389, § 212, 122 Stat. 4145, 4151 (2008) (creating new 38 U.S.C. § 5121A, substitution in case of death of a claimant who dies on or after October 10, 2008). A person eligible for substitution will include "a living person who would be eligible to receive accrued benefits due to the claimant under section 5121(a) of this title." 38 U.S.C. § 5121A The Board finds that the appellant's motion to substitute and the RO's handling of the claim were proper and that the appellant is an accrued benefits claimant pursuing those benefits that Veteran had been seeking at the time of his death in December 2012. The Board has reviewed both the Veteran's physical claims file and his electronic Virtual VA claims file to ensure a complete assessment of the evidence. FINDINGS OF FACT 1. The Veteran died in December 2012; the appellant is the Veteran's surviving spouse, who was substituted as the claimant to continue the Veteran's pending claims and appeal to completion. 2. The evidence is in relative equipoise as to whether the Veteran's degenerative disc disease of the cervical and lumbar spine was caused or aggravated by events or injury during active service and his service-connected psoriasis and shell fragment wound muscle injury disabilities. 3. The evidence is in relative equipoise as to whether the Veteran's psoriatic arthritis of the bilateral hips was caused or aggravated by events or injury during military service and his service-connected psoriasis disability. CONCLUSIONS OF LAW 1. The Veteran's surviving spouse is a proper substitute claimant in this case. 38 U.S.C.A. § 5121A (West 2002). 2. Resolving doubt in the claimant's favor, the criteria for service connection for degenerative disc disease of the cervical and lumbar spine, to include as secondary to service-connected psoriasis and shell fragment wound muscle injury disabilities, have been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. Resolving doubt in the claimant's favor, the criteria for service connection for psoriatic arthritis of the bilateral hips, to include as secondary to service-connected psoriasis, have been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). In light of the favorable decisions reached herein with respect to the claims on appeal, the Board finds that no further discussion as to VA's compliance with its duties to notify and assist is necessary at this time. II. Legal Criteria - Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Also, certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Finally, service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A layperson is competent to report symptoms that he or she experiences at any time because this requires only personal knowledge as it comes to him through his or her senses; similarly, the appellant is competent to report what she witnessed the Veteran experiencing if such experiences were capable of third party observation, such as the Veteran grimacing from low back pain. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). III. Factual Background The Veteran essentially contended that service connection is warranted for degenerative disc disease of his cervical and lumbar spine due to psoriatic arthritis that is proximately due to or caused by his service-connected psoriasis disability. Alternatively, he contended that the claimed disabilities are directly related to his military service in that he performed at least 13 parachute jumps and sustained trauma associated with a landmine explosion therein. As to his claimed hip disability, the Veteran contended that he has psoriatic arthritis of his bilateral hips, which is caused or aggravated by his service-connected psoriasis disability. As the evidence is interrelated on these issues, the Board will address jointly the claims for service connection for disability of the cervical and lumbar spine and bilateral hips. The deceased Veteran's DD Form 214 shows that he was awarded a Parachute Badge, a Purple Heart, and a Bronze Start with "V" Device. The deceased Veteran's service treatment records show that he sustained a nose laceration and a fractured nasal bone in an April 1965 motor vehicle accident, which was found to have occurred in the line of duty. In July 1966, as the result of a landmine explosion, he sustained multiple shell fragment wounds of his face, neck, and extremities; open fracture of his right hand with amputation of his right middle finger; fractured and partially anulsed teeth in the right posterior quadrant of his mouth; a right ear blast injury; and foreign bodies in both eyes. He received inpatient treatment for those injuries until September 1966 when it was noted that he experienced weakness in his legs and right hand, which resulted in a limited physical profile prohibited assignments requiring prolonged handling of heavy materials, parachute jumping, overhead work, pull-ups and pushups. In March 1967, the Veteran experienced periodic synovial entrapment due to laxity of his lateral collateral ligaments. On separation examination in June 1967, as a result of wounds sustained in Vietnam, the Veteran had loss of his right middle finger, open fracture of his right hand with residual swelling and weakness, severe laceration of his right shoulder, shrapnel wounds of his bilateral legs with full range of motion, and a scar on his right shoulder. His physical profile pertaining to his upper extremities was "3" and his physical category was listed as "C." Post-service evidence includes lay statements of the Veteran's wife and an acquaintance dated in September 1967, which indicate that when they saw the Veteran in July 1967, he was unable to walk; he had weakness of his right shoulder, arm, and hand; fingers on his right hand were stiff; and his legs became painful on driving long distances. On VA examination in September 1967, x-rays showed metallic densities consistent with shrapnel fragments over the right upper chest, right base of the neck, right shoulder, lower two-thirds of the right thigh and right anterior and lateral leg, and over the left medial and anterior leg. Physical examination of the right hand showed amputation of the right middle finger at the metacarpophalangeal joint, a 2 inch scar on the dorsum of the right hand, a flexion deformity of the right little finger with loss of extension at the proximal interphalangeal joint, moderately diminished grip, and a 2 inch scar on the palmar surface. Physical examination of the right shoulder showed full range of motion with a depressed scar with moderately severe loss of deltoid muscle tissue measuring 5 inches by 1 inch over the right deltoid muscle and a depressed scar over the dorsum of the shoulder measuring 1 inch by 1 inch with moderate loss of muscle tissue. The lower extremities were peppered with superficial scars from shell fragment wounds with full range of motion. The examiner diagnosed loss of the right middle finger, residual shell fragment wounds of the right shoulder with retained foreign bodies, residuals of multiple small wounds of the lower extremities with retained foreign bodies, scars of the right hand, and two missing teeth in the right lower quadrant of the mouth. A 1968 private treatment record from Dr. BMB Jr., M.D., showed a large defect in the right deltoid muscle area that had been skin grafted. There was some limited function and weakness of the right shoulder. On VA examination in July 1968, chest x-ray showed a few small metallic foreign bodies projected to the right base of the neck. A July 1969 private treatment note from Dr. RGJ, M.D., shows a diagnosis of generalized psoriasis with secondary infection that began to spread into areas of scars received in Vietnam and had become a threat to function of the remaining fingers on the right hand. Treatment for psoriasis at that time included methotrexate, which is a potent anti-rheumatic oral medication. In August 1969, two skin biopsies of the Veteran's mid back were compatible with psoriasis. Dr. JLC, M.D., admitted the Veteran to Duke University Medical Center for impatient treatment and observation of severe psoriasis that had proven to be resistant to treatment. Since that time, the Veteran received continuous outpatient and intermittent inpatient treatment for severe psoriasis. A September 1972 private treatment note shows complaints of back and leg pain with onset in July 1972. A September 1972 radiology report of the lumbar spine, pelvis, and hips showed no evidence of acute injury or degenerative changes. Post-service private treatment records from Dr. JSF and JSH dating from 1968 to 1996 contain a problem list with diagnoses of psoriasis with onset in 1968 and back problems "on and off" since 1975. An August 1975 private treatment note shows complaints of pain in the right hip and right low back. In September 1975, pain in the right hip and right low back traveled down to the right anterior thigh and calf. The Veteran's July 1966 landmine-related service injuries were noted along with the Veteran's report that when he first got on his feet following that incident, he could not get his right heel to the floor. It was noted that he had shrapnel in his right thigh. In March 1981, the Veteran reported knee pain since days prior without history of injury. Physical examination showed swelling and slight stiffness of the knee. A June 1983 private discharge summary showed a history of knee pain in the past, but not at that time. There were no other joint complaints. In January 1984, the Veteran complained pain in his neck, left shoulder, and down the left arm. In February 1986, the Veteran complained of a low back age since two days prior when he bent over to lift a crate. In March 1986, pain in his right hip, which traveled down to his right calf and foot made it hard to sit. Straight leg raise test was positive on the right. A March 1986 radiology reports showed a normal spine and were negative for pathology of the pelvis and right hip. In September 1986, the Veteran had tenderness in his back and across his shoulders. In February 1988, the Veteran complained of a three day history of right hip pain. It was noted that he had experienced a knee pain before and that he had a back strain for which he had taking Motrin since eleven years prior. In August 1989, the Veteran reported that prednisone taken for treatment of poison oak had reduced his back pain. In September 1989, the Veteran indicated that his back pain had been constant since three years prior. In February 1990, the Veteran complained of numbness in his left arm, soreness in his shoulders, stiffness in his neck, and tenderness of the right posterior and superior iliac crest. In October 1990, he complained of drawing in his right shoulder with tingling down the right arm since one weekend prior. On physical examination there was a little pain in the shoulders with turning the neck a certain way, slight right-sided neck tenderness, and low back pain with occasional twitching in the right posterior leg. Diagnostic impression was rule out cervical spine disease. An October 1990 VA orthopedic treatment note shows diagnostic impressions pertaining to the spine of probable degenerative disc disease of the lumbosacral juncture and probable cervical osteoarthritis with right sided brachialgia. X-ray of the cervical spine showed narrowing at C6-7 intervertebral disc space with marginal spurring with multiple fragments in the lower neck region. X-ray of the chest showed multiple metallic fragments including over the right shoulder and the right side of the neck. X-ray of the lumbosacral spine showed some spur formation of the lumbar vertebrae and slight rotary scoliosis. In February 1991, there was tenderness in the right upper sacroiliac joint for which an injection was planned. A March 1991 VA dermatology note indicated that the Veteran's psoriasis had been treated with methotrexate for greater than 20 years and that he underwent routine liver biopsies associated to his use of that medication. The Veteran had done well since his dosage of methotrexate was lowered from 15 mg to 12.5 mg in December 1990, however, he had noticed some back pain in the lumbar area. He was advised to consult his medical physician for consideration of sacroiliac joint films and lab work which may show whether he was HLA-B27 positive for the subset of psoriatic patients who might develop axial degenerative psoriatic disease. Diagnostic impression was severe psoriasis that was well controlled on current regimen and back pain of undetermined etiology. March 1991 x-rays showed mild degenerative changes at L3-4 disc space and normal sacroiliac joints. The radiographic diagnostic impression was degenerative disc disease at L3-4 and clinical diagnostic impression was mild osteoarthritis of the lumbosacral spine. May 1991 VA treatment notes show that the Veteran was evaluated for recurrent posterior cervical and lumbosacral pain of "many years in duration." Diagnostic impression was osteoarthritis of the cervical and lumbosacral spine. In an October 1991 statement, the Veteran indicated that he experienced decreased sensitivity in his right hand since several years prior and that he frequently had a stiff neck and tight shoulders. An October 1991 VA treatment note shows that x-ray examination of the lumbosacral spine showed slight scoliosis of the lumbar spine, minimal spur formation involving the bodies of the L3-4 vertebra and slight straightening of the lordotic curve. On VA examination in May 1992, the Veteran's complaints include chronic right shoulder pain that limited overhead work, and regular neck stiffness. Examination of the right shoulder showed a large soft tissue defect over the deltoid muscle just proximal to its insertion. Examination of the neck was significant for palpable shell fragments in the subcutaneous tissues. X-rays showed narrowing at C5-6, C6-7, and C2-3 intervertebral disc spaces; minimal spurring involving the bodies of the lower cervical vertebrae; and multiple foreign bodies involving the right shoulder. Diagnostic assessments included retained shell fragments in the right shoulder with residual abduction dysfunction secondary to soft tissue injury; chronic neck pain with evidence of degenerative joint and disc disease of the spine; and retained fragments in the cervical soft tissue. The examiner opined that the Veteran's neck stiffness and right shoulder pain were definitely related to traumatic injury in shell fragment damage. On VA examination in July 1992, the examiner opined that previous gunshot wound injury to the right shoulder and right hand are causatively related to limited right shoulder motion and flexion contraction with limited motion of the right hand. July 1993 VA treatment records show complaints of neck stiffness and low back pain on and off for sometime. He was now suffering increased pain in his right arm and right leg with intermittent paresthesia on the left. A history of psoriasis since 1968, treated with methotrexate, was well under control. X-ray of the lumbosacral spine showed some degree of scoliosis, moderate hypertrophic spur formation at L4 and L5, mild to moderate intervertebral disc space narrowing at L4-L5 and L5-S1, and mild intervertebral disc space narrowing at L3-L4. X-ray of the thoracic spine showed some minimal old healed traumatic residual involving the T-11 vertebral body. X-ray of the cervical spine showed intervertebral disc space narrowing at C5-C6 and C6-C7 with metallic density foreign bodies. In August 1993, the cervical spine showed foraminal encroachment at C6-C7 and the lumbosacral spine showed disc space narrowing at L4-L5 and L5-S1. In October 1993, MRI of the lumbar spine showed a herniated disc at L5-L5 and bulging discs at L3-L4 and L5-S1. In November 1993, the Veteran dated the onset of his low back pain to 1986, which had progressed to neck stiffness in the last three or four years with radicular pain to the wrists since one year prior. A January 1994 VA treatment note shows that the Veteran was referred to physical therapy due to history of low back pain (shrapnel wound). A May 1994 VA orthopedic treatment note shows diagnostic impressions of osteoarthritis of the cervical and lumbosacral spine; a left-sided herniated lumbar disc at the L5-S1 level; and land mine injuries to the cervical spine, right shoulder, and amputation of the right middle finger. On VA dermatology examination in February 1996, the examiner diagnosed extensive psoriasis vulgaris. He opined that the Veteran's skin issues dating since 1967 were consistent with psoriatic lesions that were precursors to more extensive eruption in 1968. He reasoned that the history of lesions given by the Veteran on examination is very consistent with localized psoriasis which eventually progressed to extensive psoriasis vulgaris. A March 1996 VA treatment note shows diagnostic impressions of (1) degenerative joint disease secondary to traumatic arthritis secondary to gunshot wound right shoulder and right hand, and (2) low back pain secondary to low back strain. In July 1997, the Veteran underwent neurosurgical evaluation due to history of severe progressive low back and leg pain. That same day, he underwent a lumbar laminectomy with removal of extruded disc at left L5-S1. Admission diagnosis was herniated nucleus pulpous, L5-S1. In March 1998, findings on cervical myelogram due to bilateral upper extremity pain and tingling showed diffuse degenerative changes throughout the cervical spine and an anterior deformity of the thecal sac at C6-C7. CT of the cervical spine showed diffuse spondylosis, moderate/severe spinal stenosis at C5-C6 with some cord flattening secondary to posterior uncinate spurring, and mild stenosis and moderate bilateral neuroforaminal narrowing at C6-C7, greater on the left, secondary to degenerative spurring; and mild stenosis at C4-5 and mild right neuroforaminal narrowing due to degenerative spurring. In August 1998, pain in the neck and arms prevented the Veteran from being able to work. He had no response to conservative and medical therapy. Thus, cervical laminectomy and bilateral foraminotomies at the C5-C6 and C6-C7 levels was performed. On follow-up in October 1998, Dr. DLK, Jr., M.D., did not believe that he was ready to return to work and it was noted that he was probably going to retire. In February 1999, the Office of Personnel Management approved the Veteran's application for disability retirement. In March 2000, a statement received from the Veteran's employer, the United States Postal Service, indicated that the Veteran had worked full time as a letter carrier from September 1969 to March 1999 when he received disability retirement. He last worked August 18, 1998. He performed his job well and he did not request any concessions due to disability. In February 2001, the Veteran underwent a series of VA examinations. On VA skin examination, he was diagnosed with psoriasis controlled with methotrexate and other medications with residuals. On VA spine examination, he was diagnosed with herniated nucleus populous with spinal stenosis, status post laminectomy, with residuals of the cervical spine; and status post herniated nucleus populous of the lumbosacral spine with spinal stenosis with residuals. The examiner opined that shell fragment wounds to the neck had not caused or aggravated either the Veteran's degenerative disc disease or spinal stenosis. On VA joints examination of his right shoulder, the examiner diagnosed shell fragment wounds of the right shoulder, which were resolved. The examiner stated that there was full range of motion about the shoulder without evidence of any disability. A November 2001 VA dermatology record noted the Veteran's history of psoriasis controlled with methotrexate. A long standing history of back troubles was noted and the Veteran questioned a relationship to his service-connected psoriasis (ex sacroiliitis with spondyloarthropathy). Diagnostic assessment was "? association of arthritis with psoriasis." It was noted to check RA latex, HLA B27, and lumbosacral x-ray to rule out sacroiliitis. Private rheumatology treatment records from Dr. BIW, M.D., show that in December 2001, the Veteran was noted to carry a diagnosis of psoriatic arthritis. Treatment over the last 40 years included methotrexate. Complaints included neck and low back pain, however, significant swelling of the joints was denied. Examination of the skin showed psoriatic patches primarily over the lower extremities. Following a review of diagnostic imaging of the spine since 1993, Dr. BWI diagnosed neck pain secondary to cervical osteoarthritis with limited range of motion status post surgical intervention in 1998; low back pain secondary to osteoarthritic changes status post low back surgery in 1997; psoriatic arthritis with features of degenerative arthritis based on physical examination and without evidence of rheumatoid-like picture or arthritis mutilins; and clinical findings of sacroiliitis, however, x-rays supported no evidence of severe sacroiliitis. It was noted that multiple liver biopsies had been normal and that the results and pathology reports needed to be reviewed to see if there evidence of inflammatory arthropathy. Private treatment records dated in March 2002 show a multi-year history of neck and pack pain with neck surgery 15 years prior and recurrence of neck and back pain. X-rays were noted to be consistent with degenerative disc disease and spondylosis of the cervical and lumbar spine. Diagnostic assessment was degenerative disc disease with psoriatic arthritis. On follow-up examination in June 2002, diagnostic assessment was symptomatic cervical and lumbar spine disease, with rather severe lumbar stenosis combined with disc herniation at L4-L5 and osteophytic impingement of the spinal cord at C6-C7. In July 2002, the Veteran underwent lumbar decompression and fusion for lumbar central canal stenosis at L4-L5. A June 2002 VA dermatology note indicated that the Veteran was experiencing worsening back pain and psoriasis. CBC, liver function tests, and urinalysis were all within normal limits at his last visit. HLA B27 and rheumatoid factor were negative. Results of radiographic findings of the sacroiliac joints could not be found. Diagnostic assessment was psoriasis with question of association with arthritis. September 2002 and June 2003 VA dermatology notes show that the Veteran presented for follow-up for psoriasis with complication of psoriatic arthritis. In June 2004, it was noted that the Veteran was doing great on Enbrel for treatment of psoriasis and arthritis had improved. In April 2003, the Veteran underwent a series of VA examinations. The Veteran did not particularly remember any history of injury of his cervical or lumbar spine. On VA skin examination, the Veteran indicated that he had been diagnosed with degenerative disc disease and psoriatic arthritis by a private physician, however, the VA examiner indicated that there were no associated systemic or nervous manifestations of his disease at the time of examination. The examiner stated that x-rays of the left hand did not show compatibility with psoriatic arthritis. The examiner diagnosed history of psoriasis; currently completely controlled. It was the examiners thought that any relationship between the Veteran's cervical and lumbar spine disabilities and his service-connected psoriasis disability was not definitively shown. He reasoned that no records were available and neither were any recent treatment records available. Thus, the examiner opined that there is no definite relationship between the Veteran's service-connected psoriasis and is cervical and lumbar disc and joint disease. In an October 2003 statement, the Veteran's private rheumatologist, Dr. BIW, M.D., stated that the Veteran was under his care for psoriatic arthritis and current and indefinite treatment included immunosuppressive therapy for psoriasis and psoriatic arthritis. In September 2004, the Veteran underwent a cervical decompression and laminoplasty for cervical stenosis and cervical spondylosis. A January 2008 private treatment note from the Veteran's private rheumatologist, Dr. BIW, M.D., indicated that the Veteran was last seen in June 2007 and he had returned for re-fill of medication for psoriatic arthritis, sacroiliitis, bilateral hip pain, and low back pain. The Veteran requested an x-ray examination to check for psoriatic arthritis. Following a review of previous x-rays, blood work, current medications, allergies, and past family and social history, Dr. BIW diagnosed (1) psoriatic arthritis; (2) low back pain status-post low back surgery with evidence of both vertical and horizontal osteophyte formation, which he stated is consistent not only with simple degenerative arthritis but evidence of syndesmophytes which are usually found in patients with psoriatic arthritis, inflammatory bowel disease, or Ritter's disease; (3) chronic pain; and (4) bilateral hip pain with minimal arthritis involving both right and left hips. Dr. BIW stated that in general, the Veteran has a combination of degenerative osteoarthritis and inflammatory osteoarthritis most likely secondary to underlying psoriatic arthritis involving the lower lumbosacral spine. In May 2008, the Veteran was afforded a VA spine examination. It was noted that he developed psoriasis with psoriatic arthropathy or arthritis which involved multiple joints but also the sacroiliac joint on the right upper portion of the joint. The left sacroiliac joint appeared normal on his most recent scan. His psoriasis had been a problem over the years, however, at the time of examination he was on Enbrel medication which stabilized his psoriasis and actually put it in remission as far as the skin aspect. His rheumatologist also felt some psoriatic arthropathy was causing some of his back pain. The examiner diagnosed degenerative disc disease of the lumbar spine; degenerative disc disease of the cervical spine; psoriasis with psoriatic arthritis; and psoriatic sacroiliitis involving the left upper segment of the sacroiliac joint. The examiner opined that the Veteran's degenerative disc disease, which is his main back condition, is not related to his service-connected psoriasis disability. The examiner explained that the Veteran had what appeared to be a little sacroiliitis, which may well be related to the psoriasis, but the disc problems were not secondary to his psoriasis. The examiner reasoned that there is no evidence that psoriasis cases degenerative disc disease and the Veteran's degenerative disc disease is extensive involving the cervical and lumbar spine. The examiner stated that degenerative disc disease of the cervical and lumbar spine is the Veteran's main problem and it is not caused by psoriasis nor made worse by psoriasis, which at the time of examination, was under good control with Enbrel medication. In September 2008, the Veteran underwent a VA joints examination. It was noted that he developed psoriasis in 1969 and with that he developed psoriatic arthritis which involved multiple joints of the back. He complained of bilateral hip pain that occurred with low back and neck pain. The left sacroiliac joint appeared normal on most recent scans. His psoriasis had been a problem over the years, however, treatment with Enbrel medication stabilized his psoriasis and actually put it in remission as far as the skin aspect, however, he had severe COPD and had to stop the medication and be placed back on methotrexate. He saw a rheumatologist every 6 weeks for this. He still had some low back, neck, and bilateral hip pain. He continued to have low back pain and this had been a continuing process related to his degenerative disc disease. The Veteran felt his hip pain was coming from his back. His rheumatologist also felt he had some psoriatic arthropathy causing some of his back pain. X-ray examination of the left hip was negative. X-ray of the right hip showed foreign bodies of the proximal femur and soft tissue calcium above the greater trochanter. The examiner found the bilateral hips to be normal with no hip pathology on examination. Given that no condition was found in the hips on examination, the examiner opined that the Veteran's claimed bilateral hip condition is not caused by or a result of his service-connected psoriasis. In an October 2008 statement, Dr. DDP, M.D., noted that the Veteran has significant lumbar dysfunction and multilevel degenerative problems requiring surgical intervention for decompression at L3-L4, L4-L5, and L5-S1. He opined that such conditions are, in fact, service-related dating back to the Veteran's military service in Vietnam. He requested that the Veteran be rated and treated for degenerative disease of his lumbar spine, which he stated is also service-related. In a December 2008 statement, Dr. JSF, M.D., stated that he had treated the Veteran since 1989 and he possessed private treatment records dating since 1969 which he enclosed for review. He noted that the Veteran stated that his back pain is related to his service-connected psoriasis and it is not related to his degenerative disc disease, which came much later and is not service-connected. Dr. JSF stated that he reviewed the records and he agrees with the Veteran. Specifically, records going back as early as 1972 showed complaints of back pain along with psoriasis, but x-rays at that time were reported as "no evidence of acute injury or degenerative changes appreciated." Another lumbosacral spine x-ray in March 1986 showed "normal lumbosacral spine." Dr. JSF stated that the Veteran has back pain from his psoriasis that far preceded any objective findings of degenerative disc disease and that he should be compensated for it. A December 2008 private rheumatology clinical treatment note from Dr. BIW, M.D., noted that on reviewing the Veteran's x-rays, there was evidence of both vertical and horizontal osteophytosis, which is consistent with osteoarthritis and classic syndesmophytes, which are typically found in patients with psoriatic arthritis and inflammatory arthropathy. A summary of medical findings was also significant for psoriasis, psoriatic arthritis, chronic low back pain, and bilateral hip pain with early osteoarthritis. In November 2009, the Veteran was afforded a series of VA examinations of his hips, cervical spine, and lumbar spine. Following physical examination of the Veteran and review of the claims file, the examiner diagnosed degenerative joint disease of the cervical spine. The examiner noted that the Veteran was injured in a landmine accident in 1966 and he did not see any specific complaints. X-rays did show pieces of shrapnel overlying the area of the neck and face, however, the examiner did not see any treatment for neck pain. Given the absence of treatment records, the examiner opined that it is less likely as not that the Veteran's current neck pain is related to his duties in service. He further stated that the Veteran has degenerative disc disease of his neck which is not related to his service-connected psoriasis. Regarding the lumbar spine, on examination in November 2009, the Veteran stated that his low back began bothering him in 1972 after he was discharged from military service. Pain constantly radiated to his right foot and left quad. The same medication taken for neck pain helped his low back to some degree. Following a review of the claims folder and physical examination of the Veteran, the examiner diagnosed lumbar degenerative joint disease with history of central canal stenosis. The examiner noted that there are no records of treatment for degenerative disc disease during service and it did not start bothering him until after service. Thus, the examiner opined that it is less likely as not that the Veteran's current disc disease is secondary to service activities. He further stated that the Veteran's disc disease noted in his lumbar spine is not connected to his psoriatic arthritis. As to the Veteran's bilateral hips, the Veteran indicated that his hips began to bother him in 1972. The same medication taken for spine pain helped his hip pain to some degree. The examiner noted that x-ray findings of the right hip in 2008 showed soft tissue calcium above the greater trochanter and x-ray of the left hip was negative. The examiner diagnosed bilateral hip strain. He noted that the Veteran had been diagnosed with psoriatic arthritis by a private physician, however, there were no radiographic changes noted of the hips. Thus, the examiner opined that the Veteran's current hip pan is less likely as not secondary to his psoriatic arthritis. In a September 2010 addendum, the November 2009 VA examiner noted that he was asked to clarify whether the Veteran's bilateral hip strain and sacroiliitis are at least as likely as not increased in severity by psoriasis/psoriatic arthritis. The examiner noted that on his examination of the Veteran in November 2009, x-rays of the right hip showed soft tissue calcium in the greater trochanter and the left hip was negative. Thus, stated that the Veteran's hips are not secondary to his psoriatic arthritis. He reasoned that as noted in his November 2009 report of examination, the Veteran had been diagnosed with psoriatic arthritis by a private physician, however, he had no radiographic changes in his hips. As for sacroiliitis, the examiner stated that he did not see where the Veteran has been diagnosed with such on his problem list. In a May 2011 addendum, the November 2009 VA examiner opined that the Veteran's bilateral hip strain is not at least as likely as not chronically increased in severity by psoriasis or psoriatic arthritis. He reasoned that the Veteran does not have any radiographic changes of arthritis in either hip. He acknowledged that the right hip just showed some soft tissue calcium. It was noted that the Veteran had been diagnosed with psoriatic arthritis by a private physician. Thus, the examiner stated that he did not think that the Veteran's hip strain is chronically increased in severity by his psoriasis or psoriatic arthritis. In an October 2011 addendum, the November 2009 examiner stated that following a review of the claims file and based on physical examination of the Veteran in November 2009, it is his opinion that certainly the Veteran's activities as a paratrooper can cause cervical and lumbar spine pain as well as bilateral hip pain. He stated that to what extent his paratrooper activities caused his current cervical and lumbar disease and bilateral hip pain is unknown. The examiner indicated that the best that could be stated is that the issue of whether the Veteran's bilateral hip pain and cervical and lumbar spine disease are the result of the Veteran's military duties performed as a paratrooper cannot be resolved without resort to mere speculation. In a January 2012 statement, private physician Dr. AB, D.O., indicated that the Veteran was a longstanding patient in his neurology clinic and he saw the Veteran for treatment of intractable pain with failed neck and pack syndrome status-post two cervical surgeries and four lumbar surgeries. He noted the Veteran's involvement in a land mine explosion during military service where he was severely injured, including loss of several fingers on his right hand and a probable skull base fracture with remaining shrapnel in the right maxillary sinus. He also suffered from back and neck injuries with resulting surgeries. Findings on a November 2011 CT scan of the cervical and lumbar spine were noted. Dr. AB stated that the Veteran, who was only 65 years old at the time, had advanced disc disease and problems in his neck and back. He stated that such changes are more relative to a person who is in their 80s. Dr. AB stated that it is his professional opinion that the Veteran's back and neck problems are the direct result of prior severe trauma suffered during the mine explosion in Vietnam. He reasoned that the Veteran had not family history of degenerative disc disease or other family members with history of spine surgery. Finally, the Board notes that in a March 2013 rating decision, the RO granted the claimant's claim of entitlement to service connection for the cause of the Veteran's death. In that decision, it was noted that medical evidence from the VA Compensation and Medical EPSS has established a positive associated between psoriatic arthritis and psoriasis. III. Analysis The Board finds that the evidence of record is in relative equipoise on the question of whether the Veteran's degenerative disc disease of the cervical and lumbar spine and psoriatic arthritis of the bilateral hips is etiologically related to his activities during military service and his service-connected psoriasis disability. In this regard the multiple private opinions from multiple private physicians, including a rheumatologist and neurologist who have treated the Veteran for the claimed disabilities for a number of years tend to link the claimed disabilities to the Veteran's activities during military service and his service-connected psoriasis disability. That medication used to treat the Veteran's psoriasis was also successful in treating his arthritis and degenerative disc and joint disease is also evidence in favor of the claims. Finally, while there are multiple negative VA opinions, as noted above, the VA Compensation and Medical EPSS has established a positive associated between psoriatic arthritis and psoriasis. In light of the foregoing medical evidence of a nexus between the Veteran's military service and service-connected psoriasis disability and psoriatic arthritis of his bilateral hips and his cervical and lumbar spine disabilities, resolving reasonable doubt in the appellant's favor, the Board finds that service connection is warranted for degenerative disc disease of the cervical and lumbar spine and psoriatic arthritis of the bilateral hips for accrued benefits purposes. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Entitlement to service connection for degenerative disc disease of the cervical and lumbar spine, to include as secondary to service-connected psoriasis, for accrued benefits purposes, is granted. Entitlement to service connection for psoriatic arthritis of the bilateral hips, to include as secondary to service-connected psoriasis, for accrued benefits purposes, is granted. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs