Citation Nr: 0002012 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 96-51 041 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for defective hearing. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for shingles of the scalp. 4. Entitlement to service connection for arthritis of the knees. 5. Entitlement to service connection for Osgood-Schlatter disease of the right knee. 6. Entitlement to a rating in excess of 10 percent for migraine headaches. 7. Entitlement to a compensable rating for a fracture of the proximal left second metacarpal. 8. Entitlement to a compensable rating for hemorrhoids. 9. Entitlement to a compensable rating for patellofemoral syndrome of the left knee. 10. Entitlement to a compensable rating for patellofemoral syndrome of the right knee. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARINGS ON APPEAL The veteran and his wife ATTORNEY FOR THE BOARD David A. Brenningmeyer, Counsel INTRODUCTION The veteran served on active duty from April 1970 to July 1976 and from December 1976 to October 1993. This matter comes to the Board of Veterans' Appeals (Board) on appeal from RO decisions entered in June 1994 and September 1996. This case was previously before the Board in July 1998, when it was remanded to the RO for further development. In that remand, the Board framed several of the issues here on appeal in terms of the veteran's entitlement to an increased rating. More recently, however, the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (Court) has indicated that a distinction must be made between a veteran's dissatisfaction with the initial rating assigned following a grant of service connection (so-called "original ratings"), and dissatisfaction with determinations on later filed claims for increased rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Inasmuch as each of the "rating" issues here in question was placed in appellate status by a notice of disagreement (NOD) expressing dissatisfaction with the original rating assigned, the Board has re-characterized those issues as set forth above. When the Board remanded this case in July 1998, it deferred a determination on the question whether claims of service connection for tinnitus and shingles of the scalp were properly before it. For the reasons set forth below, the Board finds that it does have jurisdiction to decide those issues. First, with respect to shingles of the scalp, the record shows that the RO denied service connection for that disability by a decision entered in June 1994. (The RO considered that disability together with a left kidney injury with hematuria, and denied service connection for both.) The veteran filed a NOD in April 1995, and was furnished a statement of the case (SOC) in September 1996. Thereafter, in November 1996, the appeal was perfected by the timely filing of a substantive appeal. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302. Second, with regard to tinnitus, the record shows that the RO denied service connection for that disability by a decision entered in September 1996. The veteran was first notified of the RO's decision by a SOC issued that same month, and expressed disagreement with the determination by a VA Form 9 filed in November 1996. Subsequently, in May 1997, his representative submitted a VA Form 646 setting forth arguments relative to the claim. Although the inclusion of the tinnitus issue in the September 1996 SOC was premature, inasmuch as the veteran had not yet been given notice of the RO's determination, or an opportunity to submit a NOD, it appears from the record that all of the requirements for an appeal have been satisfied: The veteran was notified of the decision, expressed his disagreement with it in a timely manner, was issued a SOC, and submitted additional argument within one year of the date that he was first notified of the RO's determination. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302. Consequently, it is the Board's conclusion that this issue is properly before it. Conversely, the Board finds that an appeal has not been perfected with respect to the claim of entitlement to a compensable rating for a fracture of the nose, or the claim for a rating in excess of 10 percent for spondylosis of the lumbar and dorsal spine with chronic strain. In that regard, the record shows that the veteran was notified of the RO's determinations on these issues in June 1994, that he submitted a NOD in April 1995, and that a SOC was furnished in September 1996. Thereafter, however, when he filed his substantive appeal in November 1996, he did not express a desire to further pursue these issues. Nor were these issues mentioned in a May 1997 VA Form 646 submitted by the veteran's representative. Therefore, it is the Board's conclusion that an appeal of these two issues has not been perfected. See 38 C.F.R. § 20.202 (if a SOC addresses several issues, "the Substantive Appeal must either indicate that the appeal is being perfected as to all of those issues or must specifically identify the issues appealed."). (The claims of service connection for defective hearing, arthritis of the knees, and Osgood-Schlatter disease of the right knee, and the claims for compensable ratings for patellofemoral syndrome of the knees, hemorrhoids, and a fracture of the proximal left second metacarpal are addressed in the REMAND portion of this decision.) FINDINGS OF FACT 1. When the veteran was examined for service retirement in February 1993, audiometric testing revealed puretone thresholds of 40, 15, 15, 15, and 20 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 hertz, respectively. He was discharged from service in October 1993, and filed an application for VA disability benefits for defective hearing later that same month. 2. No competent evidence has been received to link the veteran's complaints of tinnitus to service, to continued symptoms since service, or to an already service-connected disability. 3. No competent evidence has been received to show that the veteran currently has shingles of the scalp, or residuals thereof. 4. The veteran has attacks of migraine headaches three to four times per week, accompanied by dizziness and nausea; on two occasions, has he been forced to leave work and go to bed as a result of these attacks. CONCLUSIONS OF LAW 1. The claim of service connection for defective hearing in the left ear is well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.385 (1999). 2. The claim of service connection for tinnitus is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 3. The claim of service connection for shingles of the scalp is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 4. The criteria for a rating in excess of 10 percent for migraine headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.124a (Diagnostic Code 8100) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background A. Defective Hearing and Tinnitus When the veteran was examined for service entry in January 1970, his ears were found to be normal on clinical evaluation. Audiometric testing revealed puretone thresholds of 5 (20), -10 (0), -5 (5), and 0 (5) decibels in the right ear, and 10 (25), -5 (5), 0 (10), and 0 (5) decibels in the left ear, at 500, 1000, 2000, and 4000 hertz, respectively. (The report of the January 1970 examination shows that the reported figures were based on ASA standards. The figures in parentheses are ISO standard equivalents, and are reported here for purposes of facilitating comparison with more recent audiometric data.) In April 1970, audiometric testing revealed puretone thresholds of 20, 10, 10, 10, 10, and 15 decibels in the right ear, and 25, 10, 10, 10, 10, and 20 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz, respectively. In June 1970, audiometric testing revealed puretone thresholds of 5 (20), -10 (0), -5 (5), 0 (10), 0 (5), and 5 (15) decibels in the right ear, and 10 (25), -5 (5), 0 (10), 0 (10), -5 (0), and 15 (25) decibels in the left ear, at those same frequencies. In February 1972, audiometric testing revealed puretone thresholds of 15, 10, 10, 10, 5, and 20 decibels in the right ear, and 15, 10, 10, 10, 10, and 10 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz, respectively. In September 1973, audiometric testing revealed puretone thresholds of 20, 15, 30, 30, 25, and 40 decibels in the right ear, and 35, 40, 15, 10, 20, and 20 decibels in the left ear, at those same frequencies. In October 1974, audiometric testing revealed puretone thresholds of 5, 5, 15, 10, 5, and 10 decibels in the right ear, and 30, 15, 15, 15, 20 and 15 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz, respectively. In February 1975, the veteran complained of sudden onset right ear hearing loss. The clinical assessment was that he had impacted cerumen on the right. When he was examined for separation in July 1976, he denied having a history of hearing loss. It does not appear that audiometric testing was conducted. When the veteran was examined for re-entry into service in October 1976, audiometric testing revealed puretone thresholds of 10, 5, 10, 5, 5, and 5 decibels in the right ear, and 10, 10, 10, 5, 10 and 5 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz, respectively. In September 1981, the veteran indicated on a health questionnaire that he was not hard of hearing, that he had not been exposed to loud noises for long periods, and that did not have constant noises in his ears. In October 1986, audiometric testing revealed puretone thresholds of 10, 15, 20, 20, 10, and 20 decibels in the right ear, and 10, 10, 10, 5, 15, and 10 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz, respectively. When the veteran was examined in April 1987, he denied having problems with hearing loss. Audiometric testing revealed puretone thresholds of 0, 0, 10, 0, 0, and 10 decibels in the right ear, and 15, 0, 5, 0, 10, and 10 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz. When the veteran was examined in January 1989, he again denied having problems with hearing loss. Audiometric testing revealed puretone thresholds of 10, 20, 20, 15, 15, and 10 decibels in the right ear, and 15, 15, 20, 10, 20, and 10 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz, respectively. When the veteran was examined for service retirement in February 1993, he reported that he thought he was having problems with high frequency hearing loss. It was noted that the condition was not considered disabling. Audiometric testing revealed puretone thresholds of 10, 10, 15, 15, 10, and 20 decibels in the right ear, and 40, 15, 15, 15, 20, and 30 decibels in the left ear, at 500, 1000, 2000, 3000, 4000, and 6000 hertz, respectively. When the veteran was examined for VA purposes in February 1994, it was noted that he had a history of noise exposure, and that he suffered from mild, periodic, very infrequent tinnitus of uncertain onset. Audiometric testing revealed puretone thresholds of 10, 10, 10, 10, and 15 decibels in the right ear, and 10, 5, 10, 10, and 15 decibels in the left ear, at 500, 1000, 2000, 3000, and 4000 hertz, respectively. Speech discrimination scores, based on the Maryland CNC word list, were reported as 100 percent in both ears. The conclusion was that he had normal hearing, bilaterally. During a hearing held at the RO in July 1995, the veteran testified that he had difficulty hearing and understanding speech on occasion. He also indicated that he had a ringing in his ears about once or twice per week. During a videoconference hearing held before a member of the Board in June 1999, the veteran testified that he had worked in a high noise environment throughout his time in service. He said that he had been told in service that he had some hearing loss, but that his hearing was "within acceptable levels." He reported that he had trouble understanding conversational speech, and said that he occasionally had ringing in his ears. He asserted that the VA audiometric examination conducted in February 1994 was performed by a student, and was limited to puretone audiometric testing only. He also testified that he had undergone further VA auditory testing since the time of the February 1994 examination. B. Shingles of the Scalp When the veteran was examined for service entry in January 1970, his scalp was found to be normal. His scalp was also found to be normal when he was examined for service separation in July 1976. When the veteran was examined for re-entry into service in October 1976, his scalp was found to be normal. In June 1982, he complained of a tender "bump" behind his right ear. On physical examination, it was noted that he had scaling of the scalp. The clinical impression was that he had seborrheic dermatitis. In November 1984, the veteran presented for treatment of a boil on his left ear, with swelling and pain in the vicinity of his left ear, left scalp, and left neck. Examination of the scalp revealed tenderness from the occiput to the top of the forehead, and numerous three- to four-millimeter punctuate red, tender lesions. The clinical assessments were that he had a foruncle of the left pinna with early cellulitis of the left pinna and surrounding tissues, Herpes zoster of the trigeminal nerve, first division, and questionable early erysipelas. When the veteran underwent in-service examination in April 1987, January 1989, and February 1993, his scalp was found to be normal. When the veteran was examined for VA purposes in February 1994, he reported that he had had shingles in his scalp area at some point in the past. He indicated that the condition was recurrent, and that it appeared with stressful situations. On physical evaluation, no abnormalities of the skin or head were identified. The clinical impression was "[s]hingles by history." During a hearing held at the RO in July 1995, the veteran testified that he had first developed shingles of the scalp sometime between 1980 and 1983, and that he had been told that it was stress-related. He said that the condition occurred about two or three times a year, and indicated that he had last been affected six or seven months ago. When the veteran was examined for VA purposes in October 1995, he reported a history of occasional painful eruptions on his forehead and scalp. He said that the last eruption had occurred three months ago. On physical examination, it was noted that he had yellowish adherent scales and minimal erythema at the vertex and hairline, and occasional flesh- colored papules. The diagnosis was that he had probable seborrheic dermatitis. C. Migraine Headaches When the veteran was examined for service entry in January 1970, his head and vascular system were found to be normal, and he had no noted neurological abnormalities. In January 1976, he complained of an infection of the nose and headaches. In March 1976, he complained of headaches, along with symptoms such as nausea, malaise, sore throat, and dizziness. In July 1976, he reported for an optometry examination, and a history of headaches was noted. A separation examination report, also dated in July 1976, shows that he reported a history of frequent or severe headaches. On physical examination, his head and vascular system were found to be normal, and he had no noted neurological abnormalities. When the veteran was examined for re-entry into service in October 1976, his head and vascular system were found to be normal, and he had no noted neurological abnormalities. In January 1977, he complained of headaches, sinus congestion, and cough associated with rhinitis. In September 1981, the veteran indicated on a health questionnaire that he did not suffer from frequent headaches. In April 1983, the veteran complained of persistent frontal headaches. The clinical assessment was that he had tension headaches. In September 1983, he complained of headache, dizziness, and tightness of the chest and throat following a bee sting. The clinical impression was that he had had an allergic reaction. In March 1984, he complained of headache, weakness, and malaise associated with a viral syndrome. When the veteran underwent in-service examinations in April 1987 and January 1989, he denied having frequent or severe headaches. On physical evaluation, his head and vascular system were found to be normal, and he had no noted neurological abnormalities. In December 1990, the veteran presented for treatment with complaints of a recent loss of left temporal visual field, followed by a "visual unsteady feeling" and slow speech. He reported that he had had throbbing, bitemporal frontal headaches of varying degree for the last eight years, not lasting more than an hour or two, with no associated nausea. Neurological examination was normal, as was an electroencephalogram. The clinical impression was that his history was strongly suggestive of migraine. After he later gave a history of having been struck in the head by a rock while riding a motorcycle-the rock having cracked the helmet he had been wearing-the assessment was modified to indicate that the migraine was probably post-traumatic. He was treated with Inderal and Elavil. The veteran was seen for follow-up of headaches in February and March 1991. It was noted that his headaches were improved on Inderal, and that a tapering of his medication would be attempted. In May 1991, it was noted that his headaches were improved. When the veteran was examined for service retirement in February 1993, he reported a history of headaches, since resolved. It was noted that the condition was not considered disabling. On physical evaluation, his head and vascular system were found to be normal, and he had no noted neurological abnormalities. When the veteran was examined for VA purposes in February 1994, he reported having an almost constant headache for seven months following a head injury in December 1990. He indicated that he currently had headaches twice a month, some severe, located on the top of his head and in the temple area. He said that he had been able to continue working. A non-contrast computerized tomography scan of the brain was noted to be normal, and the clinical impression was that he had headaches by history. During a hearing held at the RO in July 1995, the veteran testified that his headaches were becoming more severe and frequent. He said that they occurred two to three times per week, and that some were more severe than others. He said that the most severe headaches made him feel as though his head were in a vice. He testified that he had been sent home from work on one occasion due to headaches, and said that he sometimes had to lie down to alleviate them. He said that he experienced a decrease in his peripheral vision once or twice a week, but denied having experienced any associated nausea. During a videoconference hearing held before a member of the Board in June 1999, the veteran testified that he had been experiencing attacks of migraine headache three to four times per week, on average. He indicated that at times he would go into his office at work, where he could sit in quiet and relax for 15 or 20 minutes, until his headaches "eased up" enough so that he could continue his job. He said that some attacks were more severe than others, and testified that he had had to leave work to go to bed on two occasions, when his headaches had been so severe that he had become nauseous. II. Legal Analysis A. Claims for Service Connection The veteran contends that service connection should be granted for defective hearing and tinnitus. He says that he worked in a high noise environment during service, and maintains that he now has ringing in his ears and difficulty understanding conversational speech. The veteran also contends that service connection should be granted for shingles of the scalp. He maintains that this condition first developed during his military career, and says that he still experiences flare-ups from time to time, especially during periods of stress. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303(a), 3.306 (1999). Service connection is also warranted where the evidence shows that a chronic disability or disorder has been caused or aggravated by an already service-connected disability. 38 C.F.R. § 3.310 (1999); Allen v. Brown, 7 Vet. App. 439 (1995). When disease is shown as chronic in service, or within a presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). A person who submits a claim for VA benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. Only if the claimant meets this burden does VA have the duty to assist him in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Morton v. West, 12 Vet. App. 477, 485-86 (1999). If the claimant does not meet this initial burden, the appeal must fail because, in the absence of evidence sufficient to make the claim well grounded, the Board does not have jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive, but only possible, to satisfy the initial burden of 38 U.S.C.A. § 5107(a). To be well grounded, however, a claim must be accompanied by evidence that suggests more than a purely speculative basis for granting entitlement to the requested benefits. Dixon v. Derwinski, 3 Vet. App. 261, 262-63 (1992). Evidentiary assertions accompanying a claim for VA benefits must be accepted as true for purposes of determining whether the claim is well grounded, unless the evidentiary assertion is inherently incredible or the fact asserted is beyond the competence of the person making the assertion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is plausible or possible is required. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A claimant cannot meet this burden merely by presenting lay testimony, because lay persons are not competent to offer medical opinions. Espiritu v. Derwinski, 2 Vet. App. at 495. The Court has held that evidence pertaining to each of three elements must be submitted in order to make a claim of service connection well grounded. There must be competent (medical) evidence of a current disability; competent (lay or medical) evidence of incurrence or aggravation of disease or injury in service; and competent (medical) evidence of a nexus, or link, between the in-service injury or disease and the current disability. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). This third element may also be established by the use of statutory presumptions. See 38 U.S.C.A. § 1112 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). In the present case, the Board finds that the claim of service connection for defective hearing in the left ear is well grounded. When the veteran was examined for service retirement in February 1993, audiometric testing revealed puretone thresholds of 40, 15, 15, 15, and 20 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 hertz, respectively. Under applicable regulations, those results are deemed to be indicative of a cognizable left ear hearing disability. 38 C.F.R. § 3.385 (1999) ("impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater . . . .") Given the fact that a hearing disability of the left ear was present at the time of the veteran's retirement examination, and in view of the fact that he filed an application for VA disability benefits for defective hearing in October 1993-the same month that he was separated from service-it is the Board's conclusion that the requirements for a well-grounded claim have been satisfied. See Hampton v. Gober, 10 Vet. App. 481 (1997) (Where a claim for benefits was filed one month after the veteran's separation from service, the diagnosis of a disorder in a separation examination report was deemed to constitute evidence not only of current disability, but also of a relationship between that disability and service.). To this extent, the appeal is granted. With regard to the claim of service connection for tinnitus, however, the Board finds that that claim is not well grounded. The veteran's service medical records are completely negative for complaints of tinnitus, and no competent evidence has been submitted to link his current complaints to service, to continued symptoms since service, or to an already service-connected disability. As a layperson, the veteran is not competent to offer opinions on matters of medical causation. In the absence of competent evidence showing that the veteran's current difficulties with tinnitus can in some way be attributed to service, it is the Board's conclusion the claim of service connection for that disorder cannot properly be considered well grounded. The claim must therefore be denied. It is also the Board's conclusion that the claim of service connection for shingles of the scalp is not well grounded. Although the record shows that the veteran was treated for shingles (herpes zoster) in service in 1984, no competent evidence has been submitted to substantiate his assertion that he currently suffers from that condition. Indeed, when he was examined for service retirement in February 1993, and by VA in February 1994, no abnormalities of the skin or head were identified. Furthermore, when he underwent VA dermatological examination in October 1995, his present difficulties with his scalp were attributed not to shingles, but rather to probable seborrheic dermatitis. For a claim of service connection to be deemed plausible, there must be competent medical evidence that the claimant currently has the disability for which service connection is claimed. See Degmetich v. Brown, 104 F.3d 1328, 1330-33 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Because that type of evidence has not been presented here, the Board finds that the requirements for a well grounded claim have not been satisfied. The claim must therefore be denied. B. Migraine Headaches The veteran contends that he is entitled to a rating in excess of 10 percent for migraine headaches. He maintains that he experiences migraine attacks three to four times per week, and says that they cause dizziness and nausea. He says that some attacks are more severe than others, and has offered testimony to the effect that he has on two occasions been forced to leave work and go to bed due to severe headaches. In the context of a claim for an increased rating, a mere allegation that the disability has worsened is sufficient to establish a well-grounded claim. See Arms v. West, 12 Vet. App. 188, 200 (1999); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App 629, 632 (1992). As discussed above, the veteran's claim for a rating in excess of 10 percent for migraine headaches is not a claim for an "increased" rating, but rather a claim for a higher "original" rating than that currently assigned. Nevertheless, because the two types of claims are very similar, the Board finds that the veteran's allegations alone are sufficient to make his claim well grounded. 38 U.S.C.A. § 5107(a) (West 1991). If a veteran submits a well-grounded claim, VA has a duty to assist him in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103(a), 3.159 (1999); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). The Court has held that this duty is neither optional nor discretionary. See Littke v. Derwinski, 1 Vet. App. 90, 92 (1990). In this regard, the Board notes that the veteran has been given the opportunity to testify at two hearings, and that all of the records relevant to the evaluation of his disability have been procured. The Board also notes that the veteran has not been examined by VA for purposes of assessing his headaches since February 1994, and that he has since indicated that his migraine headaches have worsened. Nevertheless, because migraine headaches are evaluated largely on the basis of subjective symptoms, and because the Board has before it recent hearing testimony from the veteran describing the frequency and severity of his migraines, it is the Board's conclusion that all of the information necessary to a proper rating of his disability has been obtained. No further assistance is required in order to fulfill the duty to assist. Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. Migraine headaches are evaluated in accordance with the criteria set forth at 38 C.F.R. § 4.124a, Diagnostic Code 8100 (1999). If characteristic prostrating attacks have averaged less than one in two months over the last several months, a zero percent rating is warranted. If prostrating attacks have occurred on an average of once in two months for the last several months, a 10 percent rating is warranted. If prostrating attacks have occurred on an average of once per month for the last several months, a 30 percent rating is warranted. The maximum schedular rating available, 50 percent, is warranted where the condition is manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. In the present case, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for migraine headaches. The veteran has indicated that he has migraine attacks three to four times per week, accompanied by dizziness and nausea. However, he says that only on two occasions has he had attacks of such severity that he has been forced to leave work and go to bed. In the Board's view, only these latter type of attacks can properly be considered "prostrating" within the meaning of applicable law. In order to be entitled to a higher rating than that currently assigned, those sorts of attacks would have occur at least once a month for several months, on average. Because the evidence establishes that they have occurred only twice in several years, the claim for a rating in excess of 10 percent must be denied. In evaluating the veteran's migraine headaches, the Board has considered whether he is entitled to a "staged rating." See Fenderson, supra. It is the Board's conclusion, however, that at no time since his service discharge has the condition been more than 10 percent disabling. Consequently, a "staged rating" is not warranted. ORDER The claim of service connection for defective hearing in the left ear is well grounded; to this extent, the appeal is granted. The claim of service connection for tinnitus is not well grounded; the claim is therefore denied. The claim of service connection for shingles of the scalp not well grounded; the claim is therefore denied. The claim for a rating in excess of 10 percent for migraine headaches is denied. REMAND As noted above, the Board has determined that the claim of service connection for defective hearing in the left ear is well-grounded. Because the claim is well grounded, VA has a duty to assist the veteran in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991). In this regard, the Board notes that the record presently contains two relatively recent reports of audiometric testing. The first report, pertaining to a service department retirement examination conducted in February 1993, reflects the presence of a left ear hearing disability within the meaning of 38 C.F.R. § 3.385 (1999). The second report, pertaining to a VA examination conducted in February 1994, indicates that the veteran's hearing is normal. Because of the discrepancy between these two reports, the Board will remand the matter so that the veteran can be re-examined, and so that an opinion can be obtained as to whether he has a left ear hearing disability that can be attributed to military service. 38 C.F.R. §§ 3.327, 19.9 (1999). The Board also notes in this regard that the veteran has testified that he underwent VA audiometric testing sometime after attending a personal hearing at the RO in July 1995. Although VA adjudicators are deemed to have constructive notice of the report of such an examination, see Bell v. Derwinski, 2 Vet. App. 611 (1992) and VAOPGCPREC 12-95 (1995), the record does not presently contain any record of VA audiometric testing after February 1994. The report of later testing, if obtained, would be relevant not only to the issue of service connection for defective hearing in the left ear, but also to the issue of service connection for defective hearing in the right ear. Consequently, on remand, the RO should undertake efforts to obtain the referenced report. With respect to the claim for a compensable rating for hemorrhoids, the veteran has indicated that that disability has increased in severity since the time of the last relevant VA examination in October 1995. It also appears that he is alleging a worsening of disability associated with the fracture of his proximal left second metacarpal, inasmuch as he apparently reported having no residual impairment during a VA examination in February 1994, and has more recently stated that he has swelling and tightness in the hand with changes in the weather, accompanied by pain and weakness of grip. In view of these allegations of increased disability, the Board will remand these two claims so that new examinations of these disabilities can be conducted. 38 C.F.R. §§ 3.327, 4.2 (1999); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As to the veteran's claim of entitlement to a compensable evaluation for patellofemoral syndrome of his knees, the Board notes that a diagnosis of that condition was not made during the veteran's most recent VA examination in October 1995. Rather, the conclusion there was that the veteran had degenerative joint disease of the knees. Because it is unclear from the current record whether the veteran still suffers from patellofemoral syndrome of the knees, or whether any of his current manifestations of knee disability can be attributed to that condition, the Board will remand the matter for a new examination. 38 C.F.R. § 3.327 (1999). In addition, because information obtained on this examination may prove germane to the pending claims of service connection for arthritis of the knees, and for Osgood-Schlatter disease of the right knee, the Board will defer adjudication of those issues until this examination has been performed. For the reasons stated, this case is REMANDED to the RO for the following actions: 1. The RO should ask the veteran to provide the RO with information regarding any evidence of current or past treatment for his knees, hemorrhoids, left index finger, and/or left ear defective hearing that has not already been made part of the record, and should assist him in obtaining such evidence following the procedures set forth in 38 C.F.R. § 3.159 (1999). The RO should make an effort to ensure that all relevant records of VA treatment have been obtained for review, including any records of VA audiometric testing conducted after February 1994. The veteran should be given a reasonable opportunity to respond to the RO's communications, and any additional evidence received should be associated with the claims folder. 2. After the above development has been completed, the veteran should be scheduled for a VA audiology examination for purposes of determining whether he has a left ear hearing disability attributable to service. If feasible, the examination should be conducted at the VA Medical Center (VAMC) in Alexandria, Louisiana. The veteran's claims folder, and a copy of this remand, should be made available to, and reviewed by, the examiner. Audiometric and speech discrimination testing should be conducted, and the results should be certified by the Chief of the Audiology Clinic. After all indicated testing has been completed, the examiner should provide an opinion as to whether the veteran has a left ear hearing impairment attributable to service. In so doing, the examiner should discuss the significance, if any, of the apparently contradictory findings contained in the report of the veteran's February 1993 military retirement examination (which reflects a puretone threshold of 40 decibels in the left ear at 500 hertz), and the reports of any subsequent audiometric examinations, including the VA audiometric examination conducted in February 1994 (which reflects a puretone threshold of only 10 decibels in the left ear at 500 hertz). A complete rationale for all opinions should be provided. 3. The veteran should be scheduled for a VA rectal examination for purposes of assessing the current severity of his service-connected hemorrhoids. If feasible, the examination should be conducted at the VAMC in Alexandria, Louisiana. The veteran's claims folder, and a copy of this remand, should be made available to, and reviewed by, the examiner. The veteran should be examined, and all indicated testing should be conducted. The examiner should fully describe the veteran's hemorrhoids, and should specifically indicate whether they are large and thrombotic; whether they are irreducible; whether there is excessive redundant tissue evidencing frequent recurrences; and whether there is evidence of persistent bleeding, anemia, or fissures. A complete rationale for all opinions should be provided. 4. The veteran should be scheduled for a VA orthopedic examination for purposes of assessing the current severity of a service-connected fracture of the veteran's proximal left second metacarpal. If feasible, the examination should be conducted at the VAMC in Alexandria, Louisiana. The veteran's claims folder, and a copy of this remand, should be made available to, and reviewed by, the examiner. The veteran should be examined, and all indicated testing, including X-ray studies, should be conducted. The examiner should fully describe all manifestations of disability affecting the left hand, provide diagnoses corresponding to those manifestations, and render an opinion, with respect to each such disorder or manifestation identified, as to whether it can be attributed to the service-connected fracture of the veteran's proximal left second metacarpal. If the examiner determines that the veteran's service- related manifestations include limitation of motion of the fingers and/or thumb, the examiner should indicate, with respect to each affected digit, whether he is able to flex the affected digit(s) to within two inches (5.1 centimeters) of the transverse fold of his palm. Then, after reviewing the veteran's complaints and medical history, the examiner should render an opinion, based upon his or her best medical judgment, as to the extent to which the veteran experiences functional impairments such as weakness, excess fatigability, incoordination, or pain due to repeated use or flare-ups, and should portray these factors in terms of additional loss in range of motion (beyond that which is demonstrated clinically) due to these factors. Specifically, the examiner should indicate, with respect to each affected digit, whether the overall disability picture, in terms of limited motion, and including weakness, excess fatigability, incoordination, and/or pain due to repeated use or flare-ups, is best described by (1) the ability or (2) inability, to flex the respective digits to within two inches (5.1 centimeters) of the transverse fold of his palm. A complete rationale for all opinions should be provided. 5. The veteran should be scheduled for a VA orthopedic examination for purposes of assessing the current severity of his service-connected bilateral knee disorder(s). If feasible, the examination should be conducted at the VAMC in Alexandria, Louisiana. The veteran's claims folder, and a copy of this remand, should be made available to, and reviewed by, the examiner. The veteran should be examined, and all indicated testing, including X-ray studies, should be conducted. The examiner should fully describe all manifestations of disability affecting the veteran's knees, provide diagnoses corresponding to those manifestations, and render an opinion, with respect to each such disorder or manifestation identified, as to whether it can be attributed to a service-related disease or injury. In so doing, the examiner should specifically indicate whether the veteran has patellofemoral syndrome of the knees, arthritis of the knees, and/or Osgood-Schlatter disease of the right knee, or residuals thereof, and whether any of these conditions, if present, can be attributed to service or an already service-connected disability. In describing the veteran's manifestations of disability, the examiner should indicate, with respect to each knee, whether the knee is ankylosed and, if so, whether it is ankylosed in full extension, or in flexion between zero and 10 degrees, 10 and 20 degrees, 20 and 45 degrees, or at 45 degrees or more; whether there is any evidence of recurrent subluxation or lateral instability and, if so, whether such subluxation and/or lateral instability is best described as slight, moderate, or severe in degree; whether the semilunar cartilage is dislocated and, if so, whether such dislocation is manifested by frequent episodes of "locking," pain, and effusion into the joint; whether the semilunar cartilage has been removed and, if so, whether there are present symptoms associated with such removal; and whether there is genu recurvatum and, if so, whether it is acquired, traumatic, and manifested by objectively demonstrated weakness and insecurity in weight-bearing. The examiner should also indicate whether there is any evidence of impairment of the tibia or fibula in terms of malunion or nonunion. If there is evidence of malunion of the tibia or fibula, the examiner should indicate whether the resulting knee disability is best described as slight, moderate, or marked in degree. If there is evidence of nonunion of the tibia or fibula, the examiner should indicate whether loose motion is present and whether a brace is required. Finally, the examiner should conduct range of motion studies on each knee. The examiner should first record the range of motion observed on clinical evaluation, in terms of degrees of flexion and extension. If there is clinical evidence of pain on motion, the examiner should indicate the degree of flexion and/or extension at which such pain begins. Then, after reviewing the veteran's complaints and medical history, the examiner should render an opinion, based upon his or her best medical judgment, as to the extent to which the veteran experiences functional impairments such as weakness, excess fatigability, incoordination, or pain due to repeated use or flare-ups, and should portray these factors in terms of degrees of additional loss in range of motion (beyond that which is demonstrated clinically) due to these factors. Specifically, the examiner should indicate, with respect to each knee, whether the overall disability picture, in terms of limited motion, and including weakness, excess fatigability, incoordination, and/or pain due to repeated use or flare-ups, is best equated with flexion which is limited to 15, 30, 45, 60, or more than 60 degrees, and/or extension which is limited to 45, 30, 20, 15, 10, 5, or less than 5 degrees. A complete rationale for all opinions should be provided. 6. The RO should thereafter take adjudicatory action on the claims of service connection for defective hearing, arthritis of the knees, and Osgood-Schlatter disease of the right knee, and the claims for compensable ratings for a fracture of the proximal left second metacarpal, hemorrhoids, and patellofemoral syndrome of the knees. With respect to the claim for a compensable rating for a fracture of the proximal left second metacarpal, and the claim for a compensable rating for the veteran's service-connected bilateral knee disorder(s), the RO should consider and apply the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59, and the Court's decision in DeLuca v. Brown, 8 Vet. App. 202 (1995). In addition, with regard to the evaluation to be assigned for the veteran's knees, the RO should consider whether separate evaluations are warranted for laxity and limitation of motion in accordance with VAOPGCPREC 23-97 (1997). If any benefit sought is denied, a supplemental SOC (SSOC) should be issued. After the veteran and his representative have been given an opportunity to respond to the SSOC, the claims folder should be returned to this Board for further appellate review. No action is required by the veteran until he receives further notice, but he may furnish additional evidence and argument while the case is in remand status. Kutscherousky v. West, 12 Vet. App. 369 (1999); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). The purposes of this remand are to procure clarifying data and to comply with governing adjudicative procedures. The Board intimates no opinion, either legal or factual, as to the ultimate disposition of this appeal. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, the Veterans Benefits Administration's Adjudication Procedure Manual, M21-1, Part IV, directs ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. LAWRENCE M. SULLIVAN Member, Board of Veterans' Appeals