Citation Nr: 21076685 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 15-45 573 DATE: December 27, 2021 ORDER An initial 30 percent rating, the schedular maximum, for irritable bowel syndrome (IBS) is granted. A 20 percent rating, but not higher, from April 17, 2017 for left upper extremity carpal tunnel syndrome (CTS) is granted. A 30 percent rating, but not higher, from April 17, 2017 for right upper extremity CTS is granted. An initial compensable rating for hemorrhoids is denied. REMANDED Entitlement to an initial compensable rating prior to August 22, 2019 for residuals of traumatic brain injury (TBI) is remanded. Entitlement to a rating higher than 30 percent from August 22, 2019 for the combined posttraumatic stress disorder (PTSD) with insomnia and TBI is remanded. Entitlement to a rating higher than 10 percent prior to January 18, 2019 for psoriasis with onychomycosis is remanded. Entitlement to a rating higher than 10 percent for left knee arthritis is remanded. Entitlement to a rating higher than 10 percent for right knee arthritis is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, during the period on appeal, his IBS has been manifested by severe symptoms with alternating diarrhea and constipation, with more or less constant abdominal distress. 2. Resolving reasonable doubt in favor of the Veteran, during the period on appeal, his left upper extremity CTS has been manifested by no more than moderate, incomplete paralysis; complete paralysis for the median nerve is not shown. 3. Resolving reasonable doubt in favor of the Veteran, during the period on appeal, his right upper extremity CTS has been manifested by no more than moderate, incomplete paralysis; complete paralysis for the median nerve is not shown. 4. During the period on appeal, the Veteran's hemorrhoids have not been manifested by large or thrombotic hemorrhoids that are irreducible with excessive redundant tissue, nor persistent bleeding with secondary anemia or with fissures. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 30 percent, the schedular maximum, for IBS have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7319. 2. The criteria for a 20 percent rating, but not higher, from April 17, 2017 for left upper extremity CTS have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8515. 3. The criteria for a 30 percent rating, but not higher, from April 17, 2017 for right upper extremity CTS have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8515. 4. The criteria for an initial compensable rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Navy from January 1993 to February 2010. These matters come before the Board of Veterans' Appeals (Board) on appeal from August 2014, January 2017, May 2017, June 2018, and July 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a June 2017 rating decision, the RO restored a 10 percent rating for psoriasis. In a June 2020 rating decision, the RO granted a 60 percent rating for psoriasis, the maximum schedular rating, effective January 18, 2019. As a higher evaluation prior to January 18, 2019 is available under the rating schedule, this claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that Veterans are presumed to seek the maximum available benefit for a disability). The 60 percent rating from January 18, 2019 constitutes a full award of the benefit sought on appeal as to that time period and is no longer in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Another RO decision issued in April 2016, during the pendency of this appeal, granted service connection additionally for PTSD and rated it initially as 30 percent disabling retroactively effective from June 24, 2015, the date of receipt of intent to file an additional claim. In a June 2020 rating decision, the AOJ assigned a single 30 percent rating for the Veteran's PTSD and TBI effective August 22, 2019, the date of a VA TBI examination. A September 2018 Board decision remanded the claims for additional development. Unfortunately, the Board finds that there has not been substantial compliance with the Board's previous remand directive with respect to increased ratings for TBI, psoriasis, and bilateral knee arthritis and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran and his representative have had the opportunity to submit an informal hearing presentation (IHP) for all issues on appeal. The Veteran and his representative did not submit additional argument on an increased rating for his IBS, hemorrhoid, and knee disabilities. With respect to the IBS and hemorrhoid claims, the Board notes that new evidence in the form of VA treatment records was obtained after the most recent February 2020 statement of the case (SOC) and that there is no waiver. However, this evidence is cumulative and thus remand for agency of original jurisdiction (AOJ) consideration is not necessary. Increased Ratings Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When considering the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection is required. Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial rating in excess of 10 percent for IBS. A July 2018 rating decision granted service connection for IBS and assigned a 10 percent rating under 38 C.F.R. § 4.114, Diagnostic Code (DC) 7319 effective from June 16, 2017. This appeal arises from the Veteran's disagreement with that decision. The Veteran contends that a higher rating is warranted based on symptoms of alternating constipation and diarrhea with abdominal distress, pain, and bloating. See NOD (August 2018); Form 9 (February 2020). The Veteran also reported that his stomach pain is near unbearable, he is prescribed medication for treatment, and that he gained over ten pounds due to his IBS. See NOD (May 2016); Correspondence (January 2018). The Board resolves reasonable doubt in favor of the Veteran and concludes that his disability is manifested by the symptoms associated with a 30 percent rating. The Veteran's IBS is rated as 10 percent disabling under 38 C.F.R. § 4.114, DC 7319. Under DC 7319, mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress, is awarded a noncompensable (0 percent) rating. Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated as 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated as 30 percent disabling. 38 C.F.R. § 4.114, Diagnostic Code 7319. In this case, VA treatment records from February 2016 show that the Veteran reported painful constipation. A May 2018 report of VA examination shows that the Veteran reported severe diarrhea, severe abdominal pain, abdominal cramping, and constipation. The Veteran also reported that his bouts of diarrhea and constipation constantly fluctuate. The examiner noted normal blood test results and no episodes of bowel disturbance with abdominal distress. A December 2019 report of VA examination shows that the Veteran reported taking MiraLax to decrease his constipation. The examiner noted symptoms of alternating diarrhea and constipation with abdominal distension. The examiner noted that the Veteran had no episodes of bowel disturbance with abdominal distress. The Board has considered the Veteran's report that he takes medication, MiraLax, which helps reduce his constipation. The Court of Appeals for Veterans Claims (Court) has held that VA may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 61 (2012). The rating criteria for DC 7319 do not contemplate the effects of medication on IBS and so the Board must consider the Veteran's symptoms without medication. The Board finds that, after discounting the ameliorative effects of medications used for treatment and resolving reasonable doubt in favor of the Veteran, the evidence supports the assignment of a 30 percent rating, but not higher. Here, attending VA clinicians noted symptoms of alternating diarrhea and constipation with abdominal distension. The Veteran has reported that his alternating diarrhea and constipation is severe, with "days of near unbearable stomach pain...." See NOD (May 2016). Although examining VA clinicians indicated no abdominal distress, neither clinician provided any discussion of the Veteran's complaints of abdominal pain, to include why such complaints did not indicate abdominal distress. As the Veteran has consistently and credibly reported abdominal pain that lasts for days with his alternating diarrhea and constipation, and after discounting the ameliorative effects of medications used for treatment, the Board finds that a 30 percent rating is warranted. Therefore, resolving reasonable doubt in favor of the Veteran, the evidence supports finding that the Veteran's IBS symptoms more nearly approximate the symptoms associated with a 30 percent rating, but not higher. Accordingly, the claim is granted. The Board has considered whether a higher rating is warranted under any other criteria for rating disabilities of the digestive system. Diagnostic Code 7323, pertaining to ulcerative colitis, provides for an increased 60 percent evaluation for a disability that is severe with numerous attacks a year and malnutrition, with health only fair during remissions. 38 C.F.R. § 4.114, Diagnostic Code 7323. The Veteran's disability has never been characterized as severe by an examining physician. There is also no medical evidence indicating that the Veteran experiences malnutrition or a decrease in his overall health due to IBS. The Board has considered whether there is any other schedular basis for granting a higher rating other than that discussed above but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for any higher ratings. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.7, 4.21. 2. Entitlement to a rating higher than 10 percent for left upper extremity CTS. 3. Entitlement to a rating higher than 10 percent for right upper extremity CTS. An unappealed October 2010 rating decision granted service connection for left and right upper extremity CTS and assigned 10 percent ratings for each extremity under 38 C.F.R. § 4.124a, DC 8515, effective from April 17, 2017. A May 2017 rating decision continued the 10 percent ratings for left and right upper extremity CTS. This appeal arises from the Veteran's disagreement with the May 2017 decision. The Veteran contends that his bilateral disability causes severe pain, tingling, and problems holding objects, and impairs his daily and work-related tasks. See NOD (May 2017); Form 9 (July 2017). The Veteran's representative reiterated those contentions in an October 2021 Appellate Brief. The Board resolves reasonable doubt in favor of the Veteran and concludes that his left and right upper extremity CTS is manifested by the symptoms associated with a 20 percent rating and 30 percent rating, respectively, but not higher. The Veteran's left and right upper extremity CTS, as paralysis of the median nerve, are both rated as 10 percent disabling for each extremity under 38 C.F.R. § 4.124a, DC 8515. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent disabling for the major extremity and 20 percent disabling for the minor extremity. Severe incomplete paralysis is rated as 50 percent disabling for the major extremity and 40 percent disabling for the minor extremity. Complete paralysis is rated as 70 percent disabling for the major extremity and 60 percent disabling for the minor extremity. 38 C.F.R. § 4.124a. In this context "minor" and "major" refer to the dominant or nondominant side. The Veteran is right-handed. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Regarding impairment of motor functions, the May 2017 VA examiner noted full strength in wrist extension, grip, and thumb to index finger pinch. The Veteran reported that severe pain and tingling in his hands causes problems holding objects and impairs work tasks. Regarding trophic changes, the May 2017 VA examiner noted no trophic changes, and the Veteran reported no skin changes beyond his service-connected psoriasis. Regarding sensory disturbance, the May 2017 VA examiner noted decreased sensation and the presence of severe paresthesias and/or dysesthesias in both upper extremities. The Veteran reported tingling in his hands. Regarding loss of reflexes, the May 2017 VA examiner noted normal deep tendon reflexes in upper and lower extremities, and the Veteran reported no impairment in his reflexes. Regarding pain, the May 2017 VA examiner noted severe intermittent pain in both upper extremities. The Veteran reported severe pain in his hands. Regarding muscle atrophy, the May 2017 VA examiner noted no muscle atrophy, and the Veteran has reported no loss of muscle or weakness. Regarding complete paralysis, the May 2017 VA examiner noted severe numbness and paresthesias and/or dysesthesias in both upper extremities but no paralysis. Median nerve tension testing in November 2018 revealed numbness and elbow pain. Based on the above, the Board finds that the bilateral disability is primarily manifest by severe pain, moderate sensory disturbance, and mild impairment of motor functions and more nearly approximates by the criteria required for a 30 percent rating for each extremity. Both the Veteran and the May 2017 VA examiner indicated the presence of severe pain, which is intermittent but not constant. Although the May 2017 examination report shows severe numbness and tingling, the Veteran had decreased, but not absent, sensation. Notably, the Veteran has not detailed his symptoms of loss of sensation beyond reported numbness and tingling. Although the May 2017 examiner noted full hand and wrist strength, the Veteran reported impairment in using his hands due to his pain and tingling. The Board also finds that the most probative evidence of record is against finding that the disability is manifest by trophic changes, loss of reflexes, muscle atrophy, or complete paralysis. Neither the Veteran's reports nor the medical evidence indicates such symptoms. The Board thus finds that the level of impairment is most analogous to moderate incomplete paralysis. A higher rating is not warranted for median nerve of either upper extremity as the Veteran's symptoms have not more nearly equated severe incomplete paralysis. Specifically, the evidence has not shown trophic changes, muscle atrophy, or loss of reflexes. Further, the severity of any sensory disturbance and/or pain has not more closely approximated severe incomplete or complete paralysis of either upper extremity. Moreover, the Veteran has not asserted that his disabilities of either upper extremity have resulted in severe incomplete or complete paralysis. Accordingly, the Board resolves all reasonable doubt in favor of the Veteran to find that a 20 percent rating for left CTS, but not higher, and a 30 percent rating for right CTS, but not higher, are warranted. In denying higher ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Although, the Veteran has indicated that his bilateral CTS has caused difficulties at work, there is no evidence or allegation that this disability has actually or effectively rendered him unable to secure and follow all substantially gainful employment at any point during this appeal. There is no indication in the record that the Veteran is unemployed. Notably, the May 2017 VA examiner found that there was no impact on the Veteran's ability to work. Under these circumstances, the Board concludes that a claim for a TDIU due to bilateral CTS has not been raised in conjunction with the instant claim for an increased rating and need not be addressed herein. 4. Entitlement to an initial compensable rating for hemorrhoids. The Veteran contends that a compensable rating is warranted based on symptoms of pain, itching, and bleeding. See NOD (August 2018); Form 9 (February 2020). The Board concludes that the disability is not shown by the more persuasive evidence to more nearly approximate the symptoms associated with a compensable rating at any point during the appeal period. A July 2018 rating decision granted service connection for hemorrhoids and assigned a noncompensable rating under 38 C.F.R. § 4.114, Diagnostic Code 7336. This appeal arises from the Veteran's disagreement with that decision. The Veteran's hemorrhoids are rated as noncompensable under 38 C.F.R. § 4.114, Diagnostic Code 7336. Diagnostic Code 7336 provides as follows: A 0 percent rating for mild or moderate hemorrhoids; a 10 percent rating for large or thrombotic, irreducible, hemorrhoids with excessive redundant tissue, evidencing frequent recurrences; a 20 percent rating for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. In this case, a May 2018 report of VA examination shows that only hemorrhoids were diagnosed. The Veteran reported rectal bleeding when he has extremely hard bowel movements. Although he refused a rectal examination, the examiner noted that his hemorrhoids were mild or moderate, as they were incidentally found during a colonoscopy in 2017. A December 2019 report of VA examination shows that only hemorrhoids were diagnosed. The Veteran reported increased itching and bleeding. The examiner noted a normal rectal examination and that the Veteran's hemorrhoids were internal and mild or moderate. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating. Here, neither the lay nor the medical evidence shows large or thrombotic recurrent hemorrhoids with excessive redundant tissue, or persistent bleeding with anemia or fissures. The Board has considered the Veteran's report that he takes medication, MiraLax, which helps reduce his hemorrhoids. The Court of Appeals for Veterans Claims has held that VA may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones, 26 Vet. App. 56. The rating criteria for DC 7336 do not contemplate the effects of medication on hemorrhoids and so the Board must consider the Veteran's symptoms without medication. Even disregarding the ameliorative effects of medications used for treatment, there is no lay or medical evidence indicating that the Veteran's hemorrhoids are large or thrombosed with excessive redundant tissue, or that they are manifested with secondary anemia or fissures. Although medication may help relieve the painful symptoms of the Veteran's hemorrhoids, there is no indication that such medication reduces the type of symptoms contemplated by a higher rating. Whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the complaints coupled with the medical evidence. Here, although the Veteran and his representative believe that the Veteran meets the criteria for a higher disability rating, the complaints and the medical findings do not meet the schedular requirements for the higher rating, as explained and discussed above. Both the lay and the medical evidence are probative here. However, it does not more nearly reflect the criteria for a higher rating under the assigned diagnostic code or any other potentially relevant code, or entitlement to a separate evaluation. Also, there is no basis to stage the rating as the evidence shows no distinct period where the disability exhibited symptoms that would warrant different ratings than assigned. Hart, 21 Vet. App. 505; Fenderson, 12 Vet. App. 119. Therefore, the preponderance of the evidence is against finding that the Veteran's hemorrhoid symptoms more nearly approximate the symptoms associated with a compensable rating. Accordingly, the claim is denied. There is no doubt to resolve. 38 U.S.C. § 5107(b);38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. Entitlement to an initial compensable rating prior to August 22, 2019 for residuals of TBI (to include claimed dizziness). 2. Entitlement to a rating higher than 30 percent from August 22, 2019 for posttraumatic stress disorder (PTSD) with insomnia and TBI. The Veteran contends that he has slurred speech from his TBI, and that the VA examiner combined his symptoms with little interaction. See NOD (June 2015); Form 9 (December 2015). The Board finds that remand is required for a medical opinion which fully contemplates all of the Veteran's symptoms. Here, the evidence shows that the Veteran reported slurred speech and that VA examiners noted intermittent slurring of speech, spontaneous speech, and occasionally impaired comprehension or interpretation of spoken words at various times during the appeal period. However, such symptoms have not been attributed to, and are not contemplated by, his service-connected PTSD and have not been fully evaluated. A July 2014 VA TBI examination report shows that the physician noted symptoms of headaches, dizziness, and slurring speech. That physician opined that there is "[n]o medical evidence that there is any associated residual problems associated with TBI at this time." See C&P Exam (July 2014). Notably, that physician indicated that a VA neurologist was unable to establish a relationship between TBI and the Veteran's complaints. The VA neurologist in question actually noted that the Veteran's symptoms are seen in patients who have suffered TBI, but that "the only way to determine whether these are related to his injuries would be whether their onset proximal to his injury could be established." See CAPRI (August 2014). However, the VA neurologist provided no opinion regarding onset. A January 2016 VA PTSD examination report shows that, although impaired speech was not noted, the psychologist noted spontaneous speech. An August 2016 VA PTSD examination report shows that the psychologist noted that symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood are attributable to PTSD. Additionally, the psychologist noted evidence of intermittent slurring of speech, but provided no indication that such symptom was part of the Veteran's PTSD, despite opining that the Veteran's symptoms of TBI and PTSD are overlapping and unable to be differentiated. An August 2019 VA TBI examination report shows that the nurse noted complaints of mild memory loss but without objective testing; subjective symptoms of headaches with dizziness, nausea, and photosensitivity; and occasionally impaired comprehension or interpretation of spoken words. That nurse opined that, other than headache symptoms (pain with dizziness, nausea, and photosensitivity), it would be speculation to attempt to differentiate between symptoms of PTSD and TBI. However, that nurse indicated that the Veteran had not been evaluated for his symptom of impaired comprehension or interpretation of spoken words. Notably, none of the previous examiners attributed speech problems to the Veteran's PTSD. A May 2020 VA nurse agreed with the August 2019 examiner that the Veteran has headache symptoms (pain with dizziness, nausea, and photosensitivity) as a residual of TBI. However, that nurse provided no opinion on whether the Veteran's noted communication impairment was a residual of TBI, and there is no indication that it was considered, despite the August 2019 examiner's note that the symptom has yet to be evaluated. Therefore, remand for an examination by a neurologist, that includes a speech evaluation, is required to ensure that VA has met its duty to assist. 38 C.F.R. § 3.159(c)(4) (VA has a duty to assist claimants by providing medical examinations); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (where VA provides an examination or obtains an opinion, it must be adequate). 3. Entitlement to a rating higher than 10 percent prior to January 18, 2019, for psoriasis with onychomycosis. The Veteran contends that a 60 percent rating is warranted prior to January 2019 as he received corticosteroid shots for treatment in April 2017, and he was told that such shots radiate and have a widespread effect. See Form 9 (July 2017). The Board finds that remand is required as the examinations provided during remand are inadequate. In this case, the November 2019 VA examiner diagnosed psoriasis and indicated that this diagnosis was a correction of the previous diagnosis of psoriasis with left great toenail onychomycosis. She explained that the Veteran's toenail abnormalities were "all due to psoriasis" and that there was no onychomycosis. She described this condition as stable. However, only the Veteran's left great toenail is contemplated by his service-connected skin disability, while the examination report indicates that three toenails on the right foot and 4 toenails on the left foot were affected. In addition, the examiner noted that the Veteran's treatment consisted of topical corticosteroids or other immunosuppressive medications, and oral retinoids. However, the Veteran reported that he received a corticosteroid shot, a Kenalog injection, in April 2017. Indeed, VA treatment records show that the Veteran was treated with a Kenalog injection in April 2017. See CAPRI at 20 (August 2017). Although the VA treatment record showing a Kenalog injection discussed both psoriasis and knee pain, the injection was provided by a Dermatologist, indicating that it was provided for treatment of psoriasis. The November 2019 report of examination provides no indication that treatment with shots/injections were considered. Additionally, the examiner provided no indication whether the Veteran's treatment with topical corticosteroids and oral retinoids was systemic in nature. The July 2021 VA skin examination contains a diagnosis of psoriasis and onychomycosis. The examiner noted no treatment with medications during the last twelve months. However, VA treatment records from September 2020 show that the Veteran had active prescriptions for Acitretin, Fluocinonide, and Calcipotriene medications for the treatment of his psoriasis. Notably, VA treatment records from April 2021 show that those psoriasis medications were refilled. In Johnson v. Shulkin, 862 F.3d 1351, 1356 (Fed. Cir. 2017), the United States Court of Appeals for the Federal Circuit held that use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court of Appeals for Veterans Claims held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. Thus, the Board finds that a VA medical opinion is required to address whether the Veteran's use of topical medications amounts to constant or near-constant systemic therapy. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Therefore, to ensure that VA has met its duty to assist, remand is required. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. 303. 4. Entitlement to a rating higher than 10 percent for left knee arthritis. 5. Entitlement to a rating higher than 10 percent for right knee arthritis. The Veteran contends that separate ratings for limitation of flexion and instability are warranted as his knees give out and he was issued hinged knee braces. See NOD (July 2018). The Veteran reports that he has knee pain, popping, and that his right knee gives out two times per week. See Form 9 (February 2020). The Board finds that remand is required to ensure that VA has fulfilled its duty to assist. 38 C.F.R. § 3.159(c)(1). In this case, VA treatment records show that the Veteran received non-VA physical therapy for his knees prior to filing his increased rating claims. VA treatment records show that the Veteran completed an initial physical therapy evaluation in September 2015, and physical therapy in February 2016, for his knees with a non-VA facility. However, those records have not been obtained. The current appeal period before the Board begins on December 16, 2015, the date VA received the Veteran's claim for an increased rating, plus the one-year "look back" period. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Therefore, to ensure that VA has met its duty to assist, remand is required. 38 C.F.R. § 3.159(c)(1). Accordingly, the matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA physical therapy treatment for bilateral knees. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for an examination by a neurologist to determine if any speech impairment (e.g. stuttering and impaired comprehension or interpretation of spoken words) since December 16, 2013 is more likely related to the Veteran's PTSD or TBI. The neurologist must perform a speech evaluation and attempt to parcel out what extent of any speech impairment is due to PTSD versus TBI since December 16, 2013. The examiner should specifically discuss the evidence of speech impairment (e.g. stuttering and impaired comprehension or interpretation of spoken words) in the July 2014, January 2016, August 2016, and August 2019 VA examinations. A complete rationale for all opinions should be given. If an opinion cannot be provided, the examiner must state why. 3. Obtain a VA medical opinion to determine the severity and manifestation of the Veteran's service-connected psoriasis with onychomycosis prior to January 18, 2019. The examiner is requested to review the claims file, to include a copy of this remand. Only if deemed necessary by the VA examiner is an actual examination required. (a) Provide the percentage of the body and percentage of exposed area affected by the psoriasis and onychomycosis. (b) The examiner should note the medications the Veteran has used to treat his skin disability prior to January 18, 2019 and the duration of such treatment, to include but not limited to Acitretin, Fluocinonide, and Calcipotriene. (c) The examiner should indicate whether each medication is topical, corticosteroid, or immunosuppressive. (d) The examiner should indicate whether the Veteran has received constant or near-constant systemic therapy, including but not limited to corticosteroids phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs. The examiner is asked to address April 2017 VA treatment records showing the Veteran received a Kenalog injection. (e) If the examiner determines that the medication is topical, the examiner should address whether it was (1) administered on a large enough scale such that it affected the body as a whole; (2) the method by which the treatment works; and (3) its side effects in determining whether the medication could be considered systemic therapy. A complete rationale must be provided for all opinions. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.