Citation Nr: 1648276 Decision Date: 12/28/16 Archive Date: 01/06/17 DOCKET NO. 16-18 666 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for neck disability. 2. Entitlement to service connection for low back disability. 3. Entitlement to service connection for left hip disability. 4. Entitlement to service connection for right hip disability. 5. Entitlement to service connection for left knee disability. 6. Entitlement to service connection for right knee disability. 7. Entitlement to service connection for acquired psychiatric disability including anxiety disorder. 8. Entitlement to an initial disability rating higher than 10 percent for psoriasis and seborrheic dermatitis. REPRESENTATION Appellant represented by: Shana Dunn, Attorney ATTORNEY FOR THE BOARD Department of Veterans Affairs INTRODUCTION The Veteran served on active duty from December 1987 to April 1992. These matters come before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. In a May 2014 rating decision, the RO denied service connection for disabilities of the neck, low back, left and right hips, and left and right knees. In an August 2015 rating decision, the RO granted service connection for psoriasis and seborrheic dermatitis, and assigned a 10 percent disability rating. The RO denied service connection for acquired psychiatric disability. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of service connection for disabilities of the neck and hips and psychiatric disability are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction, in this case, the RO. FINDINGS OF FACT 1. A motorcycle accident during service, in 1989, resulted in injuries and was immediately followed by neck complaints, but was not followed by low back complaints during service. 2. Low back disorders including lumbar spinal stenosis found at least several years after service are not attributable to the in-service accident or other events in service. 3. Left lower leg and left knee injuries from a 1989 in-service accident resolved in service without residual pathology. 4. Post-service left knee pain and arthritis are not attributable to the in-service accident or other events in service. 5. A motorcycle accident in service did not produce right knee injury then or right knee arthritis found many years after service. 6. From at least as early as 2014 forward, psoriasis and seborrheic dermatitis have covered less than 20 percent of the entire body and less than 20 percent of exposed areas, and have not required systemic therapy such as corticosteroids or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. A current low back disability including arthritis was not incurred or aggravated in service, and may not be presumed to be service connected. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 2. A current left knee disability including arthritis was not incurred or aggravated in service, and may not be presumed to be service connected. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. A current left knee disability including arthritis was not incurred or aggravated in service, and may not be presumed to be service connected. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. From the May 5, 2015, effective date of service connection for psoriasis and seborrheic dermatitis, the extent, effects, and treatment requirements of those disorders have not met the criteria for a disability rating higher than 10 percent. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Codes 7806, 7816 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2015). Under the notice requirements, VA is to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). The RO provided the Veteran notice in an August 2014 letter. In that letter, the RO notified him what information was needed to substantiate claims for service connection. The letter also addressed how VA assigns disability ratings and effective dates. The claims file contains service medical records, post-service medical records, and reports of VA medical examinations. The examination reports and other assembled records are adequate and sufficient to reach decisions on the issues that the Board is deciding at this time. The Board finds that the Veteran was notified and aware of the evidence needed to substantiate the claim, and the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining evidence. The Veteran actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Back Disability The Veteran contends that he has low back disability as a result of injuries from a motorcycle accident during service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The United States Court of Appeals for Veterans Claims (Court) has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. During service, the Veteran was in a motorcycle accident on October 8, 1989. He was taken to a private hospital emergency room. A treating clinician observed injury, with possible fracture, of the lower left leg and several abrasions on both arms. X-rays of his left leg were taken, and showed no fracture. He was transferred to a military hospital. A clinician observed multiple contusions and abrasions. X-rays were taken of his left knee, leg, and ankle and his right hand; they showed no significant abnormality. On follow-up on October 10, the Veteran reported a stiff neck and left calf pain. It was noted that in the accident he hit his leg and neck. A clinician found tenderness at both trapezius muscles. The Veteran was prescribed pain medication and placed on rest in his quarters for two days. On October 12 and in subsequent visits in October and November, he reported ongoing pain and swelling in his left leg. The records from after October 10 are silent as to the condition of his neck. Treatment records addressing the accident and ongoing effects do not reflect any report of symptoms involving his low back or address the condition of his low back. Treatment records from the remainder of his service do not address the condition of his low back. His service records reflect that he requested a service separation examination, but do not contain a record of any examination at or around the time of his separation from service. The Veteran's claims file contains no treatment records from the year following his separation from service, and no indication that he had treatment during that year. Thus there is no basis to presume service connection for arthritis in his lower spine. The Veteran's claims file contains records of VA treatment from 1998 forward. In April 1998, he reported moderate to severe low back pain. In October 1998, it was noted that he had a three year history of low back pain, with onset with a work-related pushing and twisting injury. In July 1999, he reported chronic back pain affecting his upper and lower back. He stated that a 1989 motor vehicle accident caused upper or thoracic back injury, followed by chronic pain since then. He reported that in September 1995, a few years after service, he sustained low back injury when pushing a heavy kiln. He indicated that the 1995 injury was addressed through worker's compensation, and that treatment included medication. During VA treatment in March 2004, the Veteran reported a motor vehicle accident eight days before the treatment visit. He stated that he had pain in his neck and low back. He reported a history of chronic low back pain. A clinician found that he could perform the straight leg raising test to 90 degrees bilaterally. The clinician's assessment included low back pain. In 2007, 2009, 2011, and 2012, the Veteran had VA treatment for several issues, but did not report any problems or symptoms affecting his low back. In VA treatment in March 2013, the Veteran reported back spasms. He related a twenty year history of low back pain, with a flare-up in recent days. In July 2013, CT imaging showed disc bulge and nerve root impingement at L2-L3, L4-L5, and L5-S1. In October 2013 and in April and May 2014, the Veteran reported an approximately twenty year history of intermittent pain in his neck and low back, since a motorcycle accident in service. He stated that the low back pain had worsened from about 2013 forward. He indicated that recent imaging showed herniated discs in his neck and back. Diagnoses included degenerative disc disease. On VA examination in May 2014, the Veteran reported that since a motorcycle accident in service in 1989 he had experienced muscle spasms in his low back. He stated that in late 2012 or early 2013 he collapsed due to severe low back muscle spasms, and that he had been in treatment for low back pain since. The examining physician reported having reviewed the Veteran's electronic claims file. The examiner found that the Veteran had stenosis of the thoracolumbar spine. In an April 2015 addendum to the examination report, the examiner provided the opinion that it is less likely than not that the Veteran's current lumbar spinal stenosis is related to the motorcycle accident during service. The examiner explained that his service treatment records do not document low back complaints after the accident, and that the symptoms developed many years later. In July and August 2014, persons who know the Veteran provided statements. His mother wrote that in the 1989 motorcycle accident he sustained serious injuries of the back, leg, and neck. She stated that his back injury was not adequately treated during service. She stated that he had experienced severe back pain since then. His former wife wrote that in the motorcycle accident in 1989 his leg was injured, and that he also had extreme back pain for quite some time. His brother wrote that he lived with the Veteran for a period shortly after the Veteran's separation from service. The Veteran's brother stated that during that period, and continuing through the present, the Veteran frequently related experiencing pain in his back, shoulders, and neck. In August 2014, the Veteran wrote that after the motorcycle accident in service he had severe swelling of his left leg and pain in his neck. He stated that during service he received insufficient treatment for his injuries from the accident. He reported that since separation from service he had experienced pains in his neck, back, and leg. He stated that in early 2013 he had another relapse. He asserted that spinal stenosis that had been diagnosed was due to the motorcycle accident in service. In November 2014, a private chiropractor reported that he had treated the Veteran in 1996 through 1998 and in 2004. The chiropractor stated that in 1996 the Veteran reported having been in a motorcycle accident during military service. The chiropractor indicated that he had not seen records of the treatment during service. The chiropractor stated that in 1996 the Veteran reported moderate to severe pain in his low back and his neck. The chiropractor reported that in 2004 he treated the Veteran for injuries to his neck and middle back from a March 2004 motor vehicle accident. The chiropractor wrote that in 2014 the Veteran described to him his current symptoms and recent imaging findings, although the chiropractor did not review any records. The chiropractor expressed the opinion that it is likely that the injuries from the motorcycle accident in service led to the current spinal stenosis in the Veteran's neck and low back. The Veteran sustained injuries in the 1989 motorcycle accident during service. Medical records from that time show that he reported neck pain, but do not reflect that he reported low back pain, nor do any of the records from the remainder of his service show that the problems he reported included low back problems. The earliest record of the Veteran reporting low back pain is from 1998. In 1998 and 1999, when he reported that the 1989 accident was followed by ongoing upper back pain, and that he had low back pain since a post-service workplace injury, in 1995. In 2004, he related a 2004 motor vehicle accident, and reported a history of chronic low back pain. From 2013 forward, the Veteran has in some instances indicated that intermittent low back pain had onset with the accident in service. In recent years family members have recalled that the effects of the 1989 accident included low back pain, and a chiropractor has supported a likelihood of a relationship between the accident in service and his current low back disorders. Regarding the condition of his low back after the 1989 accident, the evidence from immediately and relatively soon after that accident is more likely to be accurate than the statements made many years later based on recollections. The chiropractor did not review the service treatment records. The VA examiner, who reviewed those records, opined against a likelihood of a relationship between the accident in service and the current low back disability. Considering the lack of reports of low back symptoms in records from around the time of the 1989 accident, the evidence of post-service incidents with low back symptoms, and the medical opinion of a clinician who reviewed the service and post-service records, the greater persuasive weight of the evidence is against a relationship between the 1989 accident and the current low back disability, and thus against incurrence of the current disability in service. The Board also finds the Veteran's lay contentions to be of low probative value, as he lacks the medical training or credentials needed to provide a competent opinion as to a diagnosis or causation. The Board therefore denies service connection for the low back disability. Knee Disabilities The Veteran contends that in the motorcycle accident in service in 1989 he sustained left and right knee injuries that led to current disabilities in each knee. After the motorcycle accident in October 1989, the Veteran was initially seen at a private hospital. A treating clinician observed injury, including possible fracture, of his lower left leg. His right lower extremity appeared unremarkable. X-rays of his left lower leg showed no acute fracture or dislocation. He was transferred to a military hospital. He reported pain in his left knee and calf. A clinician observed multiple contusions and abrasions on his left lower extremity, right hand, and left hand, wrist, and elbow. The treatment notes are silent for complaints or findings involving his right lower extremity. X-rays were taken of his left knee, leg, and ankle and his right hand; they showed no significant abnormality. On follow-up during the same month, the Veteran reported a stiff neck and left calf pain. It was noted that in the accident he hit his leg and neck. A clinician found tenderness at both trapezius muscles. The Veteran was prescribed pain medication and placed on rest in his quarters for two days. During subsequent visits, he reported ongoing pain and swelling in his left leg. There were no complaints regarding his right lower extremity. Treatment records from 1990 through the end of his service in 1992 do not reflect further complaints involving his left leg or knee. In June 1990, he was seen for right foot pain after kicking a wall or door. The treating clinician found a sprain of a toe. X-rays showed no acute fracture or other significant abnormality. There were no complaints or findings regarding his right knee. Treatment records from July 1990 through the end of service do not address the condition of either knee or lower extremity. The Veteran requested a service separation examination but there is no record that he received one. The Veteran's claims file contains no treatment records from the year following his separation from service, and no indication that he had treatment during that year. Thus there is no basis to presume service connection for arthritis in either of his knees. Records of VA treatment of the Veteran in 1998, 1999, 2004, 2005, 2007, 2009, 2011, and 2012 do not reflect any complaints or problems involving either knee. In March 2013, he had treatment for severe low back pain with spasms. In August 2013, he reported a one month history of pain in both knees, worse in the right. A treating clinician examined both knees and found normal results. The clinician prescribed pain medication. Left and right knee x-rays showed mild degenerative changes and mild arthritis. In May 2014, the Veteran reported that his severe low back pain was accompanied by episodes of collapsing, with his knees giving way. On VA examination in May 2014, the Veteran reported that after recovering from the 1989 motorcycle accident he had constant mild pain in his left knee. He stated that ten to fifteen years before the 2014 examination he had begun to have flare-ups of worse left knee pain and occasional feelings of that knee giving out. He reported ongoing worsening of left knee problems. He did not report any history of right knee problems during service, after service, or at present. He indicated that he occasionally used a wheelchair, due to his back condition. The examiner reported having reviewed the Veteran's electronic claims file. On examination, the left knee had motion from 0 to 105 degrees, with no objective evidence of painful motion. The right knee had motion from 0 to 125 degrees, with no objective evidence of painful motion. The examiner stated that in each knee the range of motion was less than normal. On stability testing, both knees were normal. The examiner noted that in August 2013 x-rays showed arthritis in both knees. The examiner expressed the opinion that it is less likely than not that the Veteran's current left knee disability was caused by the 1989 injury in service or otherwise incurred in service. She explained that the service treatment records show only a contusion to that knee with the accident, and that the contusion would not cause chronic residuals. She noted that there was no medical record of left knee problems over many years following service, and that treatment records from 2013 reflect only a one month history of left knee pain. In 2014, the Veteran's mother wrote that in the 1989 motorcycle accident he sustained serious injuries of the back, leg, and neck. His former wife wrote that in the motorcycle accident in 1989 his leg was injured. In August 2014, the Veteran wrote that after the motorcycle accident in service he had severe swelling of his left leg and pain in his neck. He stated that during service he received insufficient treatment for his injuries from the accident. He reported that since separation from service he had experienced pains in his neck, back, and leg. He asserted that arthritis in his knees that had been diagnosed was due to the motorcycle accident in service. In the motorcycle accident during service, the Veteran sustained injuries of the left lower extremity. The lower leg had swelling that continued as long as a few weeks after the accident. The normal appearance of the knee on x-rays suggests that the knee did not sustain fracture or other significant bone injury. The VA physician who examined him in 2014 and considered the medical records concluded that the in-service injury to the knee was contusion. As medical records from the last two years of his service are silent as to ongoing problems affecting his left knee or leg, there is little or no contemporaneous indication of serious or ongoing left knee problems. The service records do not indicate that the accident or any other events in service affected his right knee. Records of treatment after service through 2012 do not reflect any problems with either of the Veteran's knees. When he was seen for bilateral knee pain in 2013, x-rays showed arthritis in each knee. Considering the records regarding the left knee injury and the condition of that knee after service, the 2014 VA examiner's opinion against a likelihood that current left knee pain and arthritis is related to the 1989 accident is persuasive. From 2013 forward, the Veteran has reported a history of continuous left knee pain from the 1989 accident forward. The records from around the time of that accident are more persuasive, however, with respect to the condition of that knee after the accident. Again, the Veteran has not been shown to possess the requisite training or credentials to offer a competent opinion as to medical causation or a diagnosis. Considering the history and records and the examiner's opinion, the Board concludes that the greater persuasive weight of the evidence is against incurrence of current left knee arthritis in service, including as a result of the 1989 accident. As the evidence regarding the accident and the remainder of service does not support right knee injury or problems during service, the preponderance of the evidence is against service connection for the right knee pain and arthritis found in 2013, many years after service. Psoriasis and Seborrheic Dermatitis The Veteran contends that the extent and effects of his service-connected psoriasis and seborrheic dermatitis warrant a disability rating higher than the initial 10 percent rating that the RO assigned. VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran appealed the initial 10 percent rating that the RO assigned for his skin disorders effective May 5, 2015. The Board will consider what ratings are warranted for all periods from that date forward. In a recent decision the Court found that, in determining disability ratings for dermatitis or eczema, treatment with a topical corticosteroid is a systemic therapy. See Johnson v. McDonald, 27 Vet. App. 497 (2016). VA has appealed that decision, and has placed a stay on adjudicating appeals addressed by that decision. Treatment for the Veteran's psoriasis and seborrheic dermatitis has not included any topical corticosteroid or other corticosteroid. Therefore the stay does not apply to the issue of the rating for his skin disorders. The Board will proceed with adjudicating that issue. The RO has evaluated the Veteran's psoriasis and seborrheic dermatitis under 38 C.F.R. § 4.118, Diagnostic Codes 7806 and 7816. Each of those diagnostic codes provides the same rating criteria, as follows: More than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period ......................................... 60 percent 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period ..... 30 percent At least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period ................................... 10 percent Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period ................................................................. 0 percent Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 802, 7803, 7804, or 7805), depending upon the predominant disability. Notes from VA treatment of the Veteran in September 2011 reflect that the flaking on his scalp had been improved with selenium sulfide. In April 2014, he reported itching of his face, neck, and torso. In May 2014, he reported body rashes. It was noted that he continued on selenium sulfide shampoo. Notes from May and June 2015 reflect treatment with selenium sulfide. On VA skin diseases examination in June 2015, the Veteran reported that during service he had skin disorders that affected his scalp and other areas. He stated that the disorders continued after service and worsened over time. He related that presently he used selenium sulfide 2.5% lotion on his scalp and the skin of his lower face, armpits, and chest. He reported that the medication helped. The examiner reported having reviewed the Veteran's electronic claims file. The examiner noted that the Veteran has psoriasis and seborrheic dermatitis, and that each disease was diagnosed in 1988. The examiner found that in the past 12 months he had been treated with topical selenium sulfide 2.5% for six weeks or more, but not constantly. The examiner observed that he had erythema and macular and papular lesions on his head, face, underarms, and chest, and slight flaking on his forehead. The examiner indicated that his dermatitis covered at least 5 percent but less than 20 percent of his total body area and less than 5 percent of his exposed area. The examiner stated that his skin conditions did not cause scarring or disfigurement of the head, face, or neck. The examiner stated that his skin disorders did not affect the Veteran's ability to work. VA treatment notes from July 2015 through February 2016 reflect treatment with selenium sulfide. On the 2015 examination, the Veteran's skin disorders covered less than 20 percent of his entire body and less than 20 percent of his exposed areas. Treatment and examination records reflect that from at least as early as 2011 his skin disorders have been treated with selenium sulfide, which is not a corticosteroid and is not an immunosuppressive drug. The area affected and the treatment requirements thus have not met or approached the criteria for a rating higher than 10 percent. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant's disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2015); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). The Veteran's skin disorder has not required frequent hospitalizations and has not markedly interfered with his capacity for employment. The rating criteria appropriately address the effects of this disorder. Therefore, it is not necessary to refer the issue of a ratings for this disorder, the only service-connected disorder, for consideration of extraschedular ratings. The Court has indicated that VA must consider, in an increased rating claim, whether the record indirectly raises the issue of unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has not suggested, and the record does not suggest, that his skin disorder makes him unable to secure or follow a substantially gainful occupation. Therefore the record does not indirectly raise the issue of unemployability. ORDER Entitlement to service connection for low back disability is denied. Entitlement to service connection for left knee disability is denied. Entitlement to service connection for right knee disability is denied. Entitlement to a disability rating higher than 10 percent for psoriasis and seborrheic dermatitis is denied. REMAND The Board is remanding the issues of service connection for disabilities of the neck and hips and psychiatric disability to the RO for the development of additional evidence. The Veteran contends that he has a neck disability as a result of injuries from a motorcycle accident in 1989, during his service. Service treatment records reflect that he reported neck pain after the accident. Records from the last three years of his service are silent as to the condition of his neck. There is no record of any service separation examination. In 1999, a few years after service, the Veteran reported chronic upper back pain since the accident in service. He has since reported intermittent neck pain since the accident in service. Recent medical evaluations show degenerative changes of the cervical spine. A VA physician who examined the Veteran in May 2014 expressed the opinion that it is less likely than not that the Veteran's current cervical spine disorder is related to the accident in service. The examiner stated that the Veteran had reported that current neck pain had been present for one and a half years. The examiner did not mention the Veteran's report, in 1999 treatment records, of neck pain since the 1989 accident. In December 2014, a private chiropractor opined, without reviewing service treatment records, that it is likely that the Veteran's motorcycle accident in service resulted in his current cervical spine disorders. Thus, clinicians have provided opposing opinions regarding the etiology of current neck disability, and there are questions concerning the factual bases of each opinion. The Board therefore is remanding the issue for a new VA examination with file review, consideration of the specific available information, and an opinion to regarding the likely etiology. The Veteran contends that he has left and right hip disorders as a result of injuries from a motorcycle accident during service. His VA treatment records reflect reports of a long history of pain in both hips. He has had VA examinations addressing his neck, low back, and knees, but has not had a VA examination addressing his hips. The Board is remanding those issues for an examination and file review to address the nature and likely etiology of any current hip disorders. The Veteran essentially contends that he has psychiatric problems, including anxiety and anger problems, that began during service or worsened during service. No psychiatric disorder or abnormality was noted when the Veteran was examined in December 1982 and December 1987 for entrance into his first and second periods of active service, respectively. During service, in March 1992, the Veteran had a mental health consultation that was recommended following psychological testing. He reported irritability, poor control, explosive reactions, and anxiety. The consulting psychiatrist prescribed anti-anxiety medication, listed an assessment of probable personality disorder, and recommended follow-up in two weeks. Since separation from service, the Veteran has received VA mental health treatment for issues including anxiety. He has reporting a history of anger issues since high school, before service. He has related present anxiety and panic attacks, and has attributed feelings of depression to pain and incapacity from physical disorders. He has reported that during service he destroyed records of some of the mental health treatment that he had during service. In a June 2015 VA mental disorders examination, the examiner assessed the Veteran's current condition as a personality disorder and an adjustment disorder. The examiner opined that it is less likely than not that the current adjustment disorder was incurred in service, noting indications that symptoms existed before service. The examiner opined that it is as likely as not that the current adjustment disorder is at least partly due to chronic physical pain. In light of VA's presumption, under 38 C.F.R. § 3.304, that a veteran was in sound condition when examined and accepted for service except as to disorders noted then, the Board is remanding the issue for a new examination to develop additional evidence. The examination, with file review, should provide clarification and opinion as to the nature and value of any evidence that the Veteran had a psychiatric disorder before service, had an onset of any psychiatric disorder during service, and had worsening during service of any preexisting psychiatric disorder. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA medical examination to address the nature and likely etiology of current disorders of the cervical spine and left and right hips. Provide the claims file to the examiner for review. Ask the examiner to review the file and examine the Veteran. Ask the examiner to explain the rationale for each of the opinions provided in response to the examination request. With respect to neck disability, ask the examiner to note in the file review a July 1999 VA treatment record in which the Veteran reported upper back pain since a motorcycle accident in service in 1989. Ask the examiner to provide diagnoses for each current disorder of his neck. Ask the examiner, for each current neck disorder, to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder is has continued from or is otherwise causally related to the 1989 motorcycle accident or other events in service. With respect to disabilities of the hips, ask the examiner to provide diagnoses for each current disorder of each hip. Ask the examiner, for each current disorder of each hip, to provide an opinion as to whether it is at least as likely as not that the disorder is related to events in service, including a motorcycle accident in October 1989. (CONTINUED ON NEXT PAGE) 2. Schedule the Veteran for a VA mental disorders examination to address the history and nature of any psychiatric disorders present before, during, or after his service. Provide the claims file to the examiner for review. Ask the examiner to review the file and examine the Veteran. Ask the examiner to provide opinions and findings addressing the following questions: A. Does the evidence clearly and unmistakably demonstrate that the Veteran had any psychiatric disorders before he entered service? If so, please provide a diagnosis for each such disorder. B. For each psychiatric disorder, if any, that the Veteran clearly and unmistakably had before entering service, did the disorder clearly and unmistakably NOT increase in severity during service, beyond natural progression? C. For each disorder not found to have clearly and unmistakably preexisted service, is it at least as likely as not that such disability is otherwise etiologically related to service? Ask the examiner to explain the rationale for his or her opinions. 3. Thereafter, review the expanded record and reconsider the remanded claims. If any of those claims is not granted to the Veteran's satisfaction, send him and his representative a supplemental statement of the case and give them an opportunity to respond before returning the file to the Board for further appellate consideration. The Board intimates no opinion as to the ultimate outcome of the matters that the Board has remanded. The Veteran has the right to submit additional evidence and argument on those matters. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs