Citation Nr: 18118754 Decision Date: 07/17/18 Archive Date: 07/16/18 DOCKET NO. 14-15 874 DATE: July 17, 2018 ORDER Service connection for psoriatic arthritis affecting the left elbow, right knee, right wrist, right hand, and right second, third, and fourth fingers, also claimed as polyarticular arthritis and a bone condition, is granted. Service connection for psoriasis is granted. Service connection for styes is denied. REMANDED Service connection for erectile dysfunction is remanded. Service connection for moles is remanded. Service connection for left index finger hyperkeratosis is remanded. FINDINGS OF FACT 1. The Veteran’s psoriasis and psoriatic arthritis, also claimed as polyarticular arthritis and a bone condition, affecting his left elbow, right knee, right wrist, right hand, and right second, third, and fourth fingers, were incurred during service. 2. The Veteran does not have a current stye disability. CONCLUSIONS OF LAW 1. The criteria for service connection for psoriatic arthritis affecting the left elbow, right hand, right wrist, and right second, third, and fourth fingers, are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), (d). 2. The criteria for service connection for psoriasis are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for styes are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1990 to May 1991, including service in Southwest Asia, with over 20 additional years of Reserve Service. This matter is on appeal from an April 2011 rating decision and was previously remanded by the Board of Veterans’ Appeals (Board) in December 2016. As an introductory matter, although the issues of entitlement to service connection for various joints, including the right knee, right hand, right wrist, and right fingers, were separately appealed and certified to the Board, given their common etiology (psoriatic arthritis) as discussed below, the Board has combined the claims into one issue, for purposes of expediency. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §1110; 38 C.F.R. § 3.303(a). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). 1. Psoriatic Arthritis and Psoriasis The Veteran asserts that he currently has psoriasis and psoriatic arthritis that arose during active service. Following review of the record, and resolving reasonable doubt in his favor, the Board agrees and finds that the Veteran’s currently-diagnosed psoriasis, and associated psoriatic arthritis affecting the left elbow, right knee, right wrist, right hand, and right fingers, were incurred in service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Psoriatic Arthritis Turning first to psoriatic arthritis, a November 2017 VA examination report shows a current diagnosis of psoriatic arthritis, thereby establishing a current disability. Additionally, while the Veteran’s service treatment records (STRs) are largely unavailable, the limited available service records from the Veteran’s active period of service show that, in April 1991, the Veteran complained of various joint pains that began while he was in Saudi Arabia and for which the Veteran was put on profile. Thus, in-service incurrence is also established, and the remaining question is whether the Veteran’s currently-diagnosed psoriatic arthritis was incurred in service. The Board finds that it was. In so finding, the Board finds that the most probative evidence addressing the etiology of the Veteran’s psoriatic arthritis is a November 2017 VA opinion in which the examiner concluded that the Veteran’s psoriatic arthritis is at least as likely as not related to service. That examiner noted that the Veteran was initially diagnosed in 1995 with pain in several joints that had been present for several years and was thought to be psoriatic arthritis. He then found that the Veteran appeared to have enthesopathies and joint pain consistent with the diagnosis of psoriatic arthritis that was made after service. The examiner explained that the symptoms were fairly classic for the disease, and pointed out that it takes time to have enough of them to adequately make a diagnosis. The November 2017 opinion was based on examination of the Veteran, a review of the claims file, and was supported by adequate rationale; thus, it is deemed probative. Moreover, it is entirely supported by VA and private post-service treatment records dating from as early as June 1995 that show ongoing and consistent complaints of chronic pain affecting various joints, with a reported of onset of pain in 1991 (“approximately 4 years” prior) – which, notably is entirely consistent with the April 1991 service profile for various joint pains. The Board is cognizant that, in February 2018, a different VA examiner appears to have provided a negative opinion related to the Veteran’s psoriatic arthritis. However, that opinion, as it relates to direct service connection, is of limited probative value as it appears to have been based on an inaccurate factual predicate. In that regard, notwithstanding that the Veteran’s STRs from his active duty period are actually missing – and, thus, generally not available for “review[] with care and consideration” – the examiner’s finding that “active duty medical records were negative for subjective complaints” related to orthopedic problems ignores the April 1991 service profile documenting left knee, hip, and leg pain. The examiner’s opinion also appears to have ignored the Veteran’s June 1995 report of an onset of pain involving the finger, knee, and elbow joints four years prior. Given the foregoing, the Board accords the February 2018 opinion little probative value. The Board also points out that, etiological opinions notwithstanding, the Veteran has provided competent and credible evidence of an onset of joint pains in service, of which he is competent to testify. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Furthermore, the Veteran’s description of his joint pains during service and thereafter support the current diagnosis of psoriatic arthritis that has been provided by medical professionals. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In other words, the lay evidence of record, coupled with the current diagnosis provided by clinicians, is sufficient to establish that the Veteran initially experienced joint pain due to psoriatic arthritis during service and has continued to experience that condition ever since. At a minimum, the Board finds that there is at least an approximate balance of positive and negative evidence regarding the question of whether the Veteran’s current psoriatic arthritis is related to service. In such circumstances, the Secretary is required to give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Accordingly, resolving any reasonable doubt created by the conflicting medical opinions of record in the Veteran’s favor, the Board finds that the third element required to establish service connection has been met and that service connection for psoriatic arthritis is warranted. As a final matter regarding psoriatic arthritis, the Board finds that the grant of the Veteran’s psoriatic arthritis claim encompasses his claims of entitlement to service connection for his right knee, right wrist, right hand, right fingers, and left elbow, in addition to his service connection claims for, generally, polyarticular arthritis and a bone condition. In this regard, in various reports, the November 2017 and February 2018 VA examiners attributed the Veteran’s right knee, right wrist (including DeQuervain’s disease and tenosynovitis), right hand (including tenosynovitis), and right finger disabilities (swelling) to psoriatic arthritis, and further suggested that his claimed “bone” and “polyarticular arthritis” complaints were related to his psoriatic arthritis. Indeed, a medical article discussed by the November 2017 VA examiner noted manifestations or clinical patterns of psoriatic arthritis to include symmetrical polyarthritis, and the February 2018 VA examiner found that the Veteran’s “claimed polyarticular arthritis is consistent with his diagnosis of psoriasis,” noting that the record was silent for objective evidence of a bone disease, such as osteomyelitis, and for objective evidence of degenerative arthritis. The examiner noted that imaging of various joints was either absent of evidence of definitive arthritis changes, showing “nearly preserved” or “maintained” joint spaces, or was otherwise consistent with age. Thus, the Board finds that the grant of the claim of entitlement to service connection for psoriatic arthritis also resolves the claims for polyarticular arthritis and a bone condition, in addition to the right knee, right wrist, right hand, and right second, third, and fourth fingers claims. As to the left elbow, the Board also finds that service connection is warranted as part of the psoriatic arthritis grant. In so finding, it is acknowledged that following examinations in November 2017 to specifically address psoriatic arthritis and the claimed left elbow disability, a VA examiner found that no diagnosis of a current left elbow disability was warranted, but noted left arm pain related to the Veteran leaning on his forearms at work. Similarly, the February 2018 and April 2011 VA examiners declined to provide a left elbow diagnosis and noted the Veteran’s history of keyboarding. Nevertheless, the Board observes that post-service VA and private treatment records consistently show complaints of elbow pain, and even objective elbow findings, in conjunction with his reports generalized joint pain variously diagnosed as undefined arthritis syndrome, osteoarthritis, or arthralgias, and now diagnosed as psoriatic arthritis, including in June 1995 (“joint pain in the finger, knees…and elbows”), November 1995 (noting bilateral elbow swelling and “involvement…in several of the small joints as well as elbows), February 1997 (“joint pain varies from day to day involving the elbows…” and “elbows suggestive of swelling”), January 2004 (“saw orthopedics and joint doctors for bil wrist pains, had pain in elbows”), April 2010 (“joint pains…in PIP joints through[]out & elbows & knees…”), and August 2012 (reporting intermittent pain that occurs “with other areas, elbows, wrists, hands, hips, and knees.”). Notably, the June 1995 complaints of elbow pain pre-dated most of the occupational history mentioned by the 2011, 2017, and 2018 VA examiners, and by that time, the Veteran reported a four-year history of joint pain. And, significantly, in November 1995, a private physician expressly noted a “supporting diagnosis of psoriatic arthritis [with] involvement…in several of the small joints as well as the elbows.” Moreover, to the extent that the November 2017 examiner found that a diagnosis was not warranted and noted that “the Veteran did not complain of pain in the elbow in the last exam,” the Board observes that the Veteran may not have had pain on the day of the examination, but he certainly reported a history of left elbow pain and swelling during the prior April 2011 VA examination. Similar reports were also made prior and after the examination in April 2010 and August 2012. To the extent that the February 2018 examiner also noted that a diagnosis was not warranted, the Board notes that the examiner did not perform a physical examination, and to the extent that the opinion was based on review of the record, that review appears to have been incomplete or inaccurate, as the examiner’s statement that there was no evidence of complaints of elbow pain within the presumptive period is contradicted by the Veteran’s June 1995 report of a four-year history of joint pain including in the elbows. Regardless, notwithstanding the apparent lack of elbow pain on the actual day of the April 2011 or November 2017 VA examination, the record contains complaints of left elbow pain during the period on appeal in April 2010 and August 2012, and his left elbow pain and swelling have been medically attributed to psoriatic arthritis. Thus, resolving doubt in his favor, the grant of service connection for psoriatic arthritis also encompasses his left elbow claim. Psoriasis Turning to psoriasis, VA examination reports in April 2011, November 2017 and February 2018, as well as the clinical evidence of record, show a diagnosis of psoriasis. Thus, a current disability is established. Additionally, as discussed by the VA examiners of record, psoriatic arthritis and psoriasis are related disabilities. Indeed, medical literature cited by the VA examiners supports that psoriasis and psoriatic arthritis are different manifestations of the same disease, noting that psoriasis is “a chronic inflammatory disease affecting the skin, nails, bones and joint[s] throughout the body.” Private treatment notes indicate a history of psoriasis along with a history of various joint pains as early as June 1995. Thus, as the Board has found that the Veteran’s psoriatic arthritis disability first manifested or was otherwise incurred in service, it reasons, then, that the underlying/associated disability of psoriasis was also incurred during service. As such, service connection for psoriasis is also warranted. 2. Styes Evidence of a current disability is required to establish service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability... in the absence of a proof of present disability there can be no claim.”). The requirement of a “current disability” is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Here, favorable resolution of the claim of entitlement to service connection for a stye disability requires documentation of that disability at any time during the pendency of this appeal, or at any time proximate to the filing of the claim. Notably, the Veteran has neither claimed nor submitted evidence of styes occurring in either eye proximate to or since filing his February 2010 claim. The Board acknowledges that the Veteran reported a history of styes during June 1995 treatment, and was more recently treated for a left eye stye in June 2000, and a chalazion in the left eye in September 2002. However, treatment records dated since that time are silent for evidence of styes, and none was found during a December 2017 VA examination. As the most recent evidence of a stye is dated almost eight years prior to the filing of the 2010 claim, the Board finds that the evidence simply does not document any current stye disability in either eye, and the claim for service connection for a stye disability must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is inapplicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Erectile Dysfunction The Board finds that remand of the Veteran’s erectile dysfunction service connection claim is necessary to obtain an addendum opinion. Here, a November 2017 VA examiner attributed the Veteran’s erectile dysfunction to benign prostatic hypertrophy (BPH) and opined against a nexus between erectile dysfunction and service. However, VA treatment notes show an ongoing diagnosis of primary erectile dysfunction, contradicting the finding that the Veteran’s erectile dysfunction is secondary to BPH. Furthermore, it is unclear whether the examiner actually reviewed the Veteran’s medical records, as stated, as the examiner noted that erectile dysfunction was diagnosed in 2004, but private treatment notes show treatment for erectile dysfunction in October 2001. Given the foregoing discrepancies, the Board finds that an addendum opinion should be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 2. Moles and Left Index Finger Hyperkeratosis The Board finds that remand of the Veteran’s mole and left index finger hyperkeratosis service connection claims is necessary for another examination and opinion. In this regard, the current opinions of record have either inadequate or no rationale. Specifically, the February 2018 examiner offered no explanation for concluding that the Veteran’s common moles and left finger hyperkeratosis were not related to environmental exposures during the Gulf War, and the November 2017 VA examiner appears to have relied solely upon a finding by the National Academy of Sciences (NAS) that there was inadequate and insufficient evidence to determine whether an association existed between skin conditions and Gulf War deployment. There was no discussion by any examiner of the Veteran’s heavy sun exposure, noted to be a personal risk factor by a private dermatologist in December 2003 who was examining the Veteran’s verrucous keratosis. It was held in Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009) that “[t]o permit the denial of service connection for a disease on the basis that it is not likely there is any nexus to service solely because the statistical analysis does not support presumptive service connection, would, in effect, permit the denial of direct service connection simply because there is no presumptive service connection.” The Court went on to say that, while statistical analysis can be a factor to consider when assessing whether the totality of the evidence is sufficient to establish direct service connection, it cannot be the sole basis for such a determination. Polovick, at 54. Here, as it does not appear that any VA examiner relied upon anything other than the NAS study in finding that there was no nexus between the Veteran’s Gulf War exposures and his claimed moles and left index finger hyperkeratosis, the Board finds a new examination and an addendum opinion should be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The matter is REMANDED for the following action: 1. Ask the Veteran to identify and authorize VA to obtain any outstanding private treatment records related to his claimed erectile dysfunction and skin disabilities (other than psoriasis). After obtaining any necessary authorization forms from the Veteran, obtain any pertinent records identified and associate them with the claims file. Any negative responses should be in writing and should be associated with the claims file. In addition, obtain any outstanding VA treatment records and associate them with the claims file. 2. Then, return the claims file to the examiner who conducted the November 2017 VA examination addressing erectile dysfunction to obtain an addendum opinion. If that is not possible, forward the claims file to another examiner for review. If a new examination is deemed necessary to respond to the below inquiry, one should be scheduled. Following review of the claims file, to include the relevant private treatment records dating since service, the examiner should address the following: (a) Please address the significance of the VA diagnosis of primary erectile dysfunction and reconcile that diagnosis with the November 2017 finding that the Veteran’s erectile dysfunction is secondary to benign prostate hypertrophy. (b) State whether it is at least as likely as not (50 percent probability or more) that the Veteran’s erectile dysfunction first manifested in or is otherwise related to his period of active service, to include his environmental exposures while the Veteran was serving in Southwest Asia. Please explain why or why not. 3. Then, schedule the Veteran for a VA dermatological examination. After reviewing the claims file, performing a physical examination of the Veteran, and conducting any indicated tests, the examiner is asked to address the following: (a) Please provide the diagnoses for any skin disabilities found on examination other than psoriasis. In identifying all current disorders, please consider medical and lay evidence dated both prior to and since the filing of the February 2010 claim. Please note that although the Veteran may not meet the criteria for a diagnosis at the present time, diagnoses made prior to and since the date of claim filing meet the criteria for a “current” diagnosis. (b) For any currently diagnosed skin disorder other than psoriasis, is it at least as likely as not (50 percent probability or more) that the disability arose in service or is otherwise related to service, to include environmental exposures while the Veteran was serving in Southwest Asia, including heavy sun exposure, burning oil, and rain? Please explain why or why not. Please note that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. A complete rationale for the opinions rendered must be provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and provide a supporting rationale as to why that is so. 4. After completing the requested actions, and any additional action deemed warranted, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, provide a supplemental statement of the case to the Veteran and his representative and afford them an opportunity to respond. Then, return the case to the Board, if in order. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Fagan, Counsel