Citation Nr: 21028507 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 15-13 305 DATE: May 11, 2021 THE ISSUES 1. Entitlement to service connection for bipolar disorder. 2. Entitlement to service connection for a neck disability. 3. Entitlement to service connection for a right elbow disability. 4. Entitlement to a disability rating in excess of 10 percent for a left knee disability. 5. Entitlement to a compensable disability rating from December 7, 2016, to September 25, 2018, and in excess of 30 percent from September 25, 2018 to January 20, 2021 for dermatitis and pruritus left anterior leg. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to August 25, 2016 ORDER Entitlement to a disability rating in excess of 10 percent for a left knee disability is denied. REMANDED Entitlement to service connection for bipolar disorder is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to a compensable disability rating from December 7, 2016, to September 25, 2018, and in excess of 30 percent from September 25, 2018 to January 20, 2021 for dermatitis and pruritus left anterior leg is remanded. Entitlement to a TDIU prior to August 25, 2016 is remanded. FINDING OF FACT For the entire period on appeal, the Veteran's left knee disability manifested by pain on movement of the joint, limitation of extension to zero degrees, limitation of flexion to 80 degrees, pain, weakness, and fatigability of the left knee. CONCLUSION OF LAW The criteria for an initial increased disability rating for a left knee disability greater than 10 percent have not been met or approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, Diagnostic Code 5260 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from February 1982 to February 1986. Additionally, the Veteran had active duty service from February 1987 to November 1988 but received a discharge under other than honorable conditions for that period. This case is before the Board of Veterans' Appeals (Board) on appeal from February 2014 and October 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In July 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing sitting in San Diego, California. A transcript of the hearing is of record. In an October 2019 decision, the Board observed that it appeared that not all documents had been properly associated with the claims file. Upon remand, the RO associated numerous pertinent documents, which revealed that the additional issues of service connection for a neck and elbow disability and increased disability ratings for a left knee and skin disability were and are properly before the Board. However, all of these issues were addressed in the July 2019 Board hearing. Upon remand, the RO obtained the requested documents. In a subsequent October 2020 Board decision, these matters, along with the issue of entitlement to service connection for throat cancer, were remanded for further development. In a February 2021 rating decision, the RO granted the Veteran's claim for entitlement to service connection for throat cancer. Therefore, that issue is no longer before the Board. Additionally, the February 2021 rating decision granted a staged increased rating of 60 percent effective January 20, 2021 for the Veteran's service-connected skin disability. However, this staged increase does not represent a full grant of benefits sought, and the matter is once again properly before the Board. With regards to the issue of an increased disability rating for a left knee disability, the Board finds that there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). The issues of entitlement to service connection for bipolar disorder, a right elbow disability, a neck disability, entitlement to an increased disability rating for a skin disability and entitlement to a TDIU are addressed in the REMAND portion of this decision. Entitlement to a disability rating in excess of 10 percent for a left knee disability is denied. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. Under DC 5003, degenerative arthritis, when established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate DCs, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In addition, the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact, which are diseased. Thus, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when her symptoms are most prevalent ("flare-ups") due to the extent of her pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Notably, the Court has held that pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), DC 5263 (genu recurvatum), and 5275 (shortening of the bones of a lower extremity). The criteria of DC 5256 pertain to ankylosis. Ankylosis refers to immobility and consolidation of a joint due to disease, injury, or surgical procedure). See Shipwash v. Brown, 8 Vet. App. 218, 221 (1995) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 91 (27th ed. 1988). VA amended the criteria for rating musculoskeletal disabilities effective February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board cannot apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. For claims filed prior to February 7, 2021, DC 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71 (a), DC 5257. For claims filed on or after February 7, 2021, DC 5257 provides that a knee impairment with recurrent subluxation or lateral instability is rated 10 percent for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation, 20 percent for either a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability and a medical provider prescribes a brace and/or an assistive device for ambulation or an unrepaired or failed repair of a complete ligament tear causing persistent instability and a medical provider prescribes either an assistive device or brace for ambulation, and 30 percent for an unrepaired or failed repair of a complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and a brace for ambulation. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5257). For claims filed on or after February 7, 2021, DC 5257 also provides that a knee impairment with patellar instability is rated 10 percent for a diagnosed condition involving the patellofemoral complex with recurring instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane or walker, 20 percent for a diagnosed condition involving the patellofemoral complex with recurring instability after surgical repair that requires a prescription from a medical provider for a brace, cane or walker and 30 percent for a diagnosed condition involving the patellofemoral complex with recurring instability after surgical repair that requires a prescription from a medical provider for a brace, and either a cane or a walker. Id. Lastly, for claims filed on or after February 7, 2021, DC 5257 provides that a knee impairment resulting in medial tibial stress syndrome (MTSS), or shin splints is rated 0 percent for treatment less than 12 consecutive months, one or both lower extremities, 10 percent for treatment lasting at least 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment for one or both lower extremities, 20 percent for treatment lasting at least 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity, and 30 percent for treatment lasting at least 12 consecutive months and unresponsive to surgery and either shoe orthotics or other conservative treatment for both lower extremities. Id. Under DC 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under DC 5259, a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. The DCs that focus on limitation of motion of the knee are DCs 5260 and 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a , DC 5260. Under DC 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Under Diagnostic Code 5275, shortening of the bones of a lower extremity between 1.25 and 2 inches (3.2 to 5.1 cm) warrants a 10 percent rating. A 20 percent rating is warranted for 2 to 2.5 inches (5.1 to 6.4 cm); a 30 percent rating is warranted for 2.5 to 3 inches (6.4 to 7.6 cm); a 40 percent rating is warranted for 3 to 3.5 inches (7.6 to 8.9 cm); a 50 percent rating is warranted for 3.5 to 4 inches (8.9 to 10.2 cm); and a 60 percent rating is warranted for more than four inches(10.2 cm or more). 38 C.F.R. § 4.71a, DC 5275. In general, separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has also held that "within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise." Cullen v. Shinseki, 24 Vet. App. 74 (2010). VA's Office of General Counsel has stated that compensating a claimant for separate functional impairment under DCs 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). In this opinion, the VA General Counsel held that a Veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98 (Aug. 14, 1998), the VA General Counsel further explained that if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. See also VAOPGCPREC 9-04 (Sept. 17, 2004) (which finds that separate ratings under DC 5260 for limitation of flexion of the leg and DC 5261 for limitation of extension of the leg may be assigned for disability of the same joint). The Board has reviewed all the evidence of record. Although the Board must provide reasons or bases supporting its decision, there is no legal requirement that the Board specifically discuss each item of evidence in the record. Hence, the Board will summarize the pertinent evidence for each issue as deemed appropriate, and the analysis will focus on what the evidence shows or does not show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000)). The Veteran is currently in receipt of a 10 percent disability rating for his left knee disability based on painful motion of the joint under 38 C.F.R. § 4.71a for the entire period on appeal. Historically, the Veteran filed her claim for service connection for a left knee disability in May 2013. The Veteran was awarded service connection for her right knee disability in a February 2014 rating decision and assigned an initial 10 disability rating based on painful motion of the joint. The Veteran filed a timely Notice of Disagreement (NOD) in November 2014. The Veteran filed a timely Form 9 in April 2015 and properly perfected his appeal. Turning to the medical evidence, the Veteran was first afforded a VA examination for his left knee in January 2014. The January 2014 VA examination noted complaints of left knee pain. The examiner noted diagnoses of left knee osteoarthritis and patellar tendonitis. The Veteran denied flare ups. Limitation of motion was limited to 125 degrees flexion, where pain was noted to begin. There was no limitation to extension. Repetitive use testing did not reveal any additional limitation of range of motion. The report found less movement than normal, excess fatigability, pain on movement, and swelling. There was pain on palpation. Muscle strength testing revealed active motion against some resistance for flexion and extension. Objective testing revealed no instability or patellar subluxation/dislocation. Here were no meniscal conditions or other conditions associated with the left knee. The Veteran did not use assistive devices. The Veteran's left knee disability impacted his ability to work with limitations for "athletic movements, running, jogging, [and] obstacle courses such as military and police work." A July 2014 VA treatment note recorded a diagnosis of tendonitis of the left knee with no acute fracture or dislocation, no joint effusion. Osseous mineralization was within normal limits. There was no abnormal patellar tilt or subluxation. The impression was mild osteoarthritis. An August 2014 VA treatment note reveals left knee flexion limited to 131 degrees and that the Veteran used a cane. A June 2015 knee examination revealed a clinically normal knee with full range of motion, but with asymptomatic shin splints. The Veteran complained of knee pain. The examiner explained that there was no current evidence of patellar tendonitis, but that the Veteran "should avoid prolonged running due to his shin splints condition." In his April 2015 Form 9, the Veteran argued that he deserved an increased rating for his left knee disability based on constant pain, limited mobility, and occasional giving out. In the October 2019 remand, the Board directed the RO to obtain potentially outstanding records. Such were obtained upon remand. A June 2019 treatment note obtained revealed no acute fracture, dislocation, or joint effusion. There was no lateral patellar subluxation. In the October 2020 Board decision, the board remanded the matter in order to afford the Veteran a new VA examination. Specifically, the Board found that as the Veteran's most recent left knee examination took place in June 2015, that it was necessary to remand the matter to obtain a contemporaneous examination which complies with Correia and Sharp, and which ascertains the current severity of his disability. See Caffrey v. Brown, 6 Vet. App. 377 (1994). The Veteran was afforded such a VA examination in January 2021. The report recorded a diagnosis of "left knee condition/patellar tendonitis, left knee with shin splints." The Veteran complained of pain in his left knee and is complained of numbness in his knee going down to his ankle. He also made subjective complaints of stiffness and stated he was unable to move the knee as well. He stated that he had a cane for his left knee. He reported flare ups one to two times a week which lasted a day to a month, and were characterized by increased pain, stiffness, and tightness. These flare ups were precipitated by increased movement and alleviated by acupuncture. The Veteran described them as severe and claimed he experienced a decreased ability to ambulate. Upon initial examination he Veteran's range of motion was noted to be normal extension and flexion limited to 90 degrees. There was pain noted on flexion and extension, but with no additional limitation of range of motion. Passive range of motion was the same as active. There was evidence of pain with weight-bearing, non-weight-bearing, active motion, and passive motion. This pain caused a decreased ability to bend the knee. There was objective evidence of crepitus. There was moderate localized tenderness or pain on palpation. Range of motion after repetitive use testing revealed additional limitation of range of motion of 80 degrees flexion. The examiner found pain fatigability, and lack of endurance caused functional loss. Results were identical for repeated use over time. Range of motion during flare ups was limited to 80 degrees flexion with no limitation for extension. Pain and lack of endurance contributed to functional loss with flare ups. The Veteran's right knee was not tested due to "contralateral and damage." The examiner found disturbance of locomotion and less movement than normal contributed to functional loss and/or impairment of the left knee. Muscle testing was unremarkable and upon clinical testing there was no evidence of recurrent subluxation or persistent instability. There were no ligament tears. The examiner noted that the Veteran required a prescription for a cane for his left knee ambulation. There were no meniscal conditions, and the examiner noted no tibial or fibular impairment. Finally, the examiner found that the Veteran's left knee disability impacted his employment status, stating: "[The Veteran has d]ecreased ability to walk more than 10-15 minutes without a break, decreased ability [to] walk without [a] cane, decreased ability to squat or kneel more than infrequent clime more than infrequent." VA treatment records, private treatment reports, and lay evidence discussed above, underscore that the Veteran's reports of pain. The 10 percent evaluation now contemplates pain on motion and is consistent with limitation of flexion to 80 degrees and limitation of extension to zero degrees. In order to warrant a higher evaluation, there must be the presence of the functional equivalent of limitation of flexion to 30 degrees. A separate evaluation may be assigned for compensable limitation of extension. The Veteran's service-connected right knee disability is currently rated under Code 5260, with a 10 percent rating being sustainable under 38 C.F.R. § 4.59 based on painful motion of the knee joint. At worst, the Veteran had zero to 80 degrees of flexion in the right knee, as reported in the in the January 2021 VA examination. As noted above, the normal range of motion for the knee is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2020). Clearly, this does not warrant an increased or separate disability rating assigned for limitation of flexion or extension under either diagnostic code 5260 or 5261. With regard to Diagnostic Code 5257, which pertains to recurrent subluxation or lateral instability of the knee, although the Veteran has reported subjective feelings of his left knee giving way, repeated objective testing of the right knees has revealed no recurrent subluxation or lateral instability. In that regard, the Board acknowledges that the Veteran is competent to report experiencing such symptoms as giving way of the knee. However, after reviewing the medical treatment evidence of record, the Board finds that the collective medical evidence of record reflects no objective evidence of instability. At the January 2021 Compensation and Pension Examination, he did not have a history of recurrent subluxation or knee instability, and joint stability testing revealed "normal" Lachman test, posterior drawer test, medial stability, and lateral stability in the left knee. In fact, her stability has consistently been deemed normal throughout the record according to objective testing. The Board finds that the competent medical evidence weighs against a finding that the Veteran's service-connected left knee disability manifested in at least slight recurrent subluxation or lateral instability. The Board places weight on the medical evidence because the various tests were developed to specifically measure instability and were administered by specially trained and educated medical professionals. For these reasons, the Board finds that an additional rating based on instability of the right knee is not warranted under Diagnostic Code 5257. See English v. Wilkie, 30 Vet. App. 347 (2018). There is no evidence of ankylosis; consequently Code 5256 does not apply. There is also no evidence a meniscal condition. Consequently, Codes 5258 and 5259 do not apply. Finally, the Veteran has not been shown to have a compensable level of a shortening of the bones of the lower extremity, therefore Code 5275 does not apply. In short, an increased rating is not warranted under any applicable criteria. The Board has considered the provisions of 38 C.F.R. §§ 4.40 and 4.4 and DeLuca, 8 Vet. App. at 202, but finds that when reviewing the evidence of record related to limitation of motion, weakened motion, excess motion, incoordination, fatigability, and pain on motion, there is no indication, even on repetitive testing, that the next higher ratings would be available to the Veteran under the applicable criteria. REASONS FOR REMAND 1. Entitlement to service connection for bipolar disorder is remanded. The Veteran filed a claim for service connection for an acquired psychiatric disability, characterized as bipolar disorder, on May 16, 2014. This claim was denied by the RO in October 2014 and the Veteran timely initiated and perfected an appeal. The voluminous medical records show treatment for various reported psychiatric disabilities. For example, a VA treatment note dated October 2008 stated that the Veteran was being treated for PTSD and Bipolar disorder. An April 2014 letter from a VA psychiatrist, Dr. S.M., indicated that the Veteran had bipolar disorder and that he had been under his care since 2000. The Veteran attended a VA PTSD examination in December 2015. The examiner found that the Veteran had been suffering from PTSD symptoms for several years but expressed doubt with the Veteran's bipolar diagnosis. On the list of current psychiatric diagnoses, the VA examiner only listed PTSD and a polysubstance abuse disability in remission. In its October 2020 decision, the Board remanded the matter in order to afford the Veteran a VA psychological examination and opinion. The examiner was asked to address and explain the conclusion in the April 2014 letter from a VA psychiatrist, Dr. S.M., indicating that the Veteran had bipolar disorder, had been under his care since 2000, and that the disability was likely the result of the Veteran's service. A VA psychological examination was conducted in January 2021. The examiner concluded that the Veteran did not meet the DSM-V criteria for bipolar disorder. However, the examiner did not reconcile his findings with the April 2014 letter from Dr. S.M. Therefore, the Board finds that an additional remand is necessary in order to comply with the Board's October 2020 remand directives. Stegall, 11 Vet. App. 268, 271 (1998). 2. Entitlement to service connection for a neck disability is remanded. 3. Entitlement to service connection for a right elbow disability is remanded. In April 2014, the Veteran submitted a private medical opinion from his primary care provider, Dr. P.W., in which the physician opined that the Veteran's neck and right elbow pain were likely the result of a fall he had in service. However, no rationale was offered. The Veteran was afforded a VA examination for his claimed neck disability in September 2018. The examiner confirmed a diagnosis of degenerative disc disease of the cervical spine, however, found that it was not at least as likely as not due to his right wrist disability, reasoning that the disabilities were separate and distinct, with separate and distinct etiologies. The examiner concluded by noting that a right wrist sprain is unlikely to cause degenerative disc disease of the neck. The examiner did not address the positive nexus opinion by Dr. P.W. Additionally, in March 2017, a VA examiner opined that the Veteran's right cubital tunnel disability was not at least as likely as not due to his service-connected right wrist disability. The examiner stated that there was no medical evidence associating the right wrist disability with cubital tunnel neuropathy and that the Veteran did not have any neuropathy until 30 years later. The examiner did not address the positive nexus opinion by Dr. P.W. However, a May 2018 VA treatment note states the following: "It seems that his wrist pain (which was manifested during his service) is most likely caused by compression in his elbow and neck, which also most likely happened during service (as his wrist pain was the manifesting symptom). [The Veteran] recently had surgery to his right elbow to release the ulnar nerve which cased increase in pain to his right wrist (most likely due to improved signal of pain from pinch in neck). [The Veteran] currently still has pain in right wrist, will be going to Ortho-spine for follow up on right neck cervical radiculopathy to see if releasing this may help with his service-connected right wrist pain. I believe that his r cervical spine and r elbow conditions are a direct cause of his right wrist pain, and hopefully, correcting his right cervical spine condition may help with his symptoms." In its October 2020 decision, the Board found that it remained unclear if the Veteran's neck and right elbow disabilities are etiologically related to his service, to include as due to his service-connected right wrist disability. The Board therefore remanded that matter and directed, the RO to obtain new VA medical opinions which address the May 2018 VA treatment note and the April 2014 private medical opinions. Specifically, the Board directed that the examiner must address the May 2018 VA treatment note and the April 2014 private positive medical opinion by Dr. P.W., and, if necessary, the examiner must reconcile her or his findings with those documents. The Veteran was afforded such VA examinations in January 2021. Regarding the Veteran's claimed right elbow disability, the examiner found that the Veteran did not have a current right elbow condition. The examiner wrote "the abnormalities noted for the right elbow are due to right elbow cubital tunnel, which is outside the scope of the exam, therefore, no diagnoses are warranted at this time." With regards to the Veteran's neck disability, the examiner In a disorganized, contradictory, and incomprehensible opinion, the examiner seemed to opine that the Veteran's right elbow disability, for which he had not provided an examination, was etiologically related to his service-connected right wrist disability. In the same opinion, the examiner seemed to opine that the Veterans neck disability was not etiologically related to the service connected right wrist disability, but did not adequately reconcile that opinion with the May 2018 VA treatment note and the April 2014 private medical opinions. Instead, the examiner copied and pasted information from the claims file at the foot of this opinion but did not provide context or analysis as to the importance of each piece of information. As the examination and opinions are inadequate for purposes of determining etiology, and do not substantially comply with the October 2020 Board remand directives, the Board finds that an additional remand is necessary to afford the Veteran adequate examinations and opinions. Stegall, 11 Vet. App. 268, 271 (1998). 4. Entitlement to a compensable disability rating from December 7, 2016, to September 25, 2018, and in excess of 30 percent from September 25, 2018 to January 20, 2021 for dermatitis and pruritus left anterior leg is remanded . The Veteran contends that he is entitled to an initial disability rating for dermatitis and pruritus of the left anterior leg, in excess of 0 percent prior to September 25, 2018, in excess of 30 percent thereafter. After a review of the record, the Board finds that a remand is necessary for an additional VA medical opinion. The Veteran's skin disability is rated under DC 7806 for dermatitis or eczema. In this regard, under 38 C.F.R. § 4.118, DC 7806, a noncompensable rating is warranted where the skin disability covers less than 5 percent of the entire body or exposed areas affected, and no more than topical therapy was required during the past 12-month period; a 10 percent rating is warranted where the skin disability covers at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of the exposed areas affected, or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period; a 30 percent rating is assigned when the disorder covers 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or by systemic therapy being required for a total duration of six weeks or more, but not constantly, during the past 12-month period; and a 60 percent rating is assigned when the disorder covers more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or by constant or near-constant systemic therapy being required during the past 12-month period. The Board notes that the 60 percent rating criteria was changed on August 13, 2018, after the Veteran's claim for an increased rating. Since August 13, 2018, a 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or 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 required over the past 12-month period. Claims pending prior to the effective date of the new 60 percent rating, such as in the present case, shall be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. There is evidence that during the time on appeal, the Veteran used topical medications to treat his disability. In an April 2017 VA examination, the examiner noted the constant/near-constant use of the topical corticosteroid, TAC cream, during the past 12 months. A private medical examination in October 2018 noted that the Veteran was using two other "topical corticosteroid" 6 weeks or more, but not constantly over the previous 12 months. In light of the recently decided Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017) (topical corticosteroids could conceivably be considered systemic therapy if administered on a large enough scale to affect the body as a whole), the Board must consider whether the Veteran's possible use of topical corticosteroids, antifungal medication, and ointments may be considered a systemic therapy. In the October 2020 decision, the Board found that there was evidence that the Veteran has possibly been prescribed topical corticosteroids and uses them on a constant or near constant basis. In light of the Court's decision in Johnson, the Board found that a remand was necessary to obtain a medical opinion which addressed whether any of the Veteran's topical medications prescribed for his skin disability constitute intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. The Board specifically requested that an opinion be obtained from a specialist in skin disease and/or medical profession in dermatology. The Veteran was afforded a new VA skin examination in January 2021. However, the examiner was not a skin disease specialist or dermatologist. Additionally, the examiner indicated that the Veteran underwent light therapy. Based upon the findings of the January 2021 examiner, the Veteran was awarded a 60 percent rating for his skin disability effective January 20, 2021. While 60 percent is the highest allowable disability rating under DC 7806, such a rating was not assigned for the entire period on appeal and therefore, the matter of an increased disability rating prior to January 20, 2021 is still properly before the Board. For the reasons listed above, the Board finds that an additional medical opinion is necessary in order to comply with the October 2020 Board remand directives and to determine whether any of the Veteran's treatments prior to January 20, 2021 could be considered systemic therapy as contemplated by the DC 7806. 5. Entitlement to a TDIU prior to August 25, 2016 is remanded. The Veteran has asserted that his medical issues have made him unable to work. Generally, TDIU is awarded on a schedular basis, which requires that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The Veteran has been awarded a TDIU effective August 25, 2016. See April 2017 rating decision. Therefore, entitlement to a TDIU from that date has been rendered moot. Because the intertwined issues that would affect his determination for a TDIU are being remanded, his TDIU claim must be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Obtain any outstanding and relevant VA and/or private treatment records. Should such exist, associate them with the claims folder. 2. Thereafter, schedule the Veteran for a new VA examination by an appropriate medical professional for the purpose of ascertaining the current nature and likely etiology of his claimed psychiatric disabilities including bipolar disorder, to exclude post-traumatic stress disorder (PTSD). The entire claims file, including this decision, must be reviewed by the examiner, and a note that it was reviewed should be included in the report. After reviewing the claims file and examining the Veteran, the examiner should answer the following questions: Is it least as likely as not (a fifty percent probability or greater) that any diagnosed psychiatric disorder, other than PTSD, is related to his active duty, to include as due to a ship collision? The examiner is asked to address and explain the conclusion in the April 2014 letter from a VA psychiatrist, Dr. S.M., indicating that the Veteran had bipolar disorder, had been under his care since 2000, and that the disability was likely the result of the Veteran's service. If the examiner determines that the Veteran does not meet the DSM-V criteria for bipolar disorder, he or she must reconcile those findings with the above mentioned evidence. A detailed rationale for the opinion must be provided. Review of the entire claims file is required. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 3. After completion of the first directive, forward the Veteran's claims file to a qualified medical professional to obtain an addendum opinion as to the nature and etiology of the Veteran's neck disability. If the clinician determines that an examination is necessary, one should be scheduled. After reviewing the record, including lay evidence submitted by the Veteran, the examiner must also provide and opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's neck disability is etiologically related to active service, to include as secondary to his service connected right wrist disability. A full rationale must be provided. The examiner must address the May 2018 VA treatment note and the April 2014 private positive medical opinion by Dr. P.W. If necessary, the examiner must reconcile her or his findings with those documents. A detailed rationale for the opinion must be provided. Review of the entire claims file is required. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 4. After completion of the first directive, forward the Veteran's claims file to a qualified medical professional to obtain an addendum opinion as to the nature and etiology of the Veteran's right elbow disability. If the clinician determines that an examination is necessary, one should be scheduled. After reviewing the record, including lay evidence submitted by the Veteran, the examiner must also provide and opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's right elbow disability is etiologically related to active service, to include as secondary to his service connected right wrist disability. A full rationale must be provided. The examiner must address the May 2018 VA treatment note and the April 2014 private positive medical opinion by Dr. P.W. If necessary, the examiner must reconcile her or his findings with those documents. A detailed rationale for the opinion must be provided. Review of the entire claims file is required. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 5. After completion of the first directive, arrange for the Veteran's electronic claims file, including a copy of this remand, to be reviewed by a specialist in skin disease and/or medical profession in dermatology to determine the nature of the Veteran's treatments for his skin disability for the purpose of preparing an addendum opinion. The entire claims file, including a copy of this remand, must be made available to, and be reviewed by, the VA examiner. Another examination is not required; however, if the VA examiner indicates that he cannot respond to the Board's questions without examination of the Veteran, another examination should be afforded to the Veteran. The VA examiner should note the Veteran's past and current skin medications throughout the period on appeal, specifically, those cited in the April 2017, October 2018, and January 2021 examinations, and any more listed in the medical record. After identifying all medication and light treatments used by the Veteran for the service-connected skin disorder during the period on appeal and prior to January 20, 2021, the examiner should indicate whether each is a systemic therapy that is like or similar to corticosteroids or other immunosuppressive drugs. The examiner is asked to define the periods in which the Veteran used each specific medication. (Continued on next page.) 6. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of TDIU. 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. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. E. Geary, 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.