Citation Nr: 0002641 Decision Date: 02/02/00 Archive Date: 02/10/00 DOCKET NO. 92-15 288 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for mitral valve prolapse. 2. Entitlement to service connection for auritis. 3. Entitlement to service connection for a disorder manifested by leg cramps. 4. Entitlement to service connection for hypothyroidism. 5. Entitlement to service connection for residuals of a left adrenalectomy. 6. Entitlement to service connection for a disorder manifested by swollen lymph nodes. 7. Entitlement to service connection for a psychiatric disorder. 8. Entitlement to an initial evaluation in excess of 10 percent for fibromyositis. 9. Entitlement to an initial evaluation in excess of 10 percent for migraine headaches. 10. Entitlement to an initial evaluation in excess of 10 percent for duodenal ulcers. REPRESENTATION Appellant represented by: The American Legion INTRODUCTION The veteran served on active duty from March 1982 to June 1991. This case comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from the Department of Veterans Affairs (hereinafter VA) regional office in St. Petersburg, Florida (hereinafter RO). The issue of entitlement to service connection for auritis is addressed in the remand portion of this decision. FINDINGS OF FACT 1. Leg cramps are symptoms and not a disability for which service connection may be granted. 2. There is no medical evidence of record that any residuals of an adrenalectomy conducted prior to service entrance were aggravated by active military duty. 3. Mitral valve prolapse, confirmed by diagnostic tests, is not currently shown. 4. There is no medical evidence of record that the veteran currently has hypothyroidism. 5. There is no medical evidence showing a nexus between any current psychiatric disorder and service. 6. Manifestations of the veteran's fibromyositis of the lumbosacral spine and hips include slight limitation of motion of the lumbar spine. 7. Manifestations of the veteran's duodenal ulcers produce mild impairment, with recurring symptoms once or twice yearly. 8. Manifestations of the veteran's migraines include nausea, hyperacusis, and photophobia, which occur approximately once a month and are incapacitating for several days. CONCLUSIONS OF LAW 1. The claims of entitlement to service connection for a disorder manifested by leg cramps, hypothyroidism, a psychiatric disorder, and residuals of a left adrenalectomy are not well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. Mitral valve prolapse was not incurred in or aggravated by active military duty. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991). 3. The criteria for an initial evaluation in excess of 10 percent for fibromyositis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Code 5021 (1999). 4. The criteria for an initial evaluation in excess of 10 percent for duodenal ulcer have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.114, Diagnostic Code 7305 (1999). 5. The criteria for an initial evaluation of 30 percent, but no more, for migraines have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(16), 1110, 1131 (West 1991). The law provides that "a person who submits a claim for benefits under a law administered by the [VA] shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a). Establishing a well-grounded claim for service connection for a particular disability requires more than an allegation that the disability had its onset in service or is service-connected; it requires evidence relevant to the requirements for service connection and of sufficient weight to make the claim plausible and capable of substantiation. See Franko v. Brown, 4 Vet. App. 502, 505 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The three elements of a "well grounded" claim are: (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the in-service disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet. App. 498 (1995); see also 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (1999). Generally, competent medical evidence is required to meet each of the three elements. However, for the second element the kind of evidence needed to make a claim well grounded depends upon the types of issues presented by a claim. Grottveit v. Derwinski, 5 Vet. App. 91, 92-93 (1993). For some factual issues, such as the occurrence of an injury, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnoses, competent medical evidence is required. Id. at 93. A. Leg Cramps In claiming service connection for leg cramps, the veteran is claiming service connection for symptoms rather than for an underlying disability from which the symptoms derive. The veteran's service medical records reveal that in December 1986, she complained of pain in both legs after prolonged periods of standing. The assessment was anterior compartment syndrome. In July 1988, cramping in the upper and lower extremities was complained of. The impression of the examiner was possible early fibromyositis. With regard to the element of a claim for service connection requiring the existence of a current disability, the Board notes that a veteran's statements as to subjective symptomatology alone, such as leg cramps, without current medical evidence of an underlying impairment capable of causing the symptom alleged, generally cannot constitute plausible evidence of the existence of a current disability for VA service connection purposes. Although anterior compartment syndrome was shown in service, the Board notes that most recently, examiners have attributed the symptomatology experienced in the lower extremities to fibromyositis, a service-connected disorder. Therefore, to the extent that the symptoms are contemplated in the ratings assigned for this service-connected disorder, the Board notes that VA is precluded from compensating them under various diagnoses. 38 C.F.R. § 4.14 (1999). Thus, the Board finds that the symptoms of leg cramps for which the veteran claims service connection is not shown to constitute a separate disability from the service-connected fibromyositis. Therefore, the Board concludes that, because there is no evidence to render plausible that leg cramps are a separate and distinct disability in itself, no evidence has been presented or secured to render plausible a claim that leg cramps constitutes a "current disability" for the purposes of establishing a well grounded claim for service connection. Accordingly, the claim for service connection for leg cramps is not well grounded. 38 U.S.C.A. § 5107(a). B. Residuals, Left Adrenalectomy The veteran's service medical records reveal that she underwent a left adrenalectomy prior to service entrance. Although there are numerous entries in service and subsequent thereto that the veteran underwent a left adrenalectomy, there is no medical evidence that any residuals thereto were aggravated by the veteran's period of active military service. In August 1984, a diagnosis of viral upper respiratory infection versus allergic symptoms; rule out adrenal insufficiency was made. However, no further findings were reported. A summary of the veteran's medical history prepared in January 1988, reported a left adrenalectomy prior to service entrance, and the veteran stated that she had no problems since that time. Subsequent to service discharge, the veteran complained of abdominal pain in 1993. Mild left adrenal tenderness was found. The impression was pelvic inflammatory disease. In 1995, the veteran complained of fatigue and generalized body ache. The impression was chronic fatigue syndrome versus possible mild adrenal insufficiency. A pre-existing disorder is considered to be aggravated where there is an increase in disability during service, unless due to the natural progress of the disorder. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306 (1999). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. Id. As there is no medical evidence of record that any residuals of an adrenalectomy conducted prior to service entrance, were aggravated by the veteran's active military duty, the claim of entitlement to service connection for residuals of a left adrenalectomy is not well-grounded, and must be denied. C. Mitral Valve Prolapse The veteran's service medical records reveal that the veteran was diagnosed with mitral valve prolapse in December 1984. She was treated with medication, but in September 1985, it was noted that she was not tolerating the medication, and it was changed. Thereafter, in February 1987, clinical notes that medication was discontinued in December 1986. An echocardiogram report dated in July 1987, confirmed the existence of a mitral valve prolapse. The veteran continued to complain of symptoms, to include sharp pains in chest, dizziness, syncope, and faintness. The veteran was hospitalized in January 1988; the discharge diagnoses included mitral valve prolapse. On discharge from hospitalization in January 1990, the diagnoses included asymptomatic mitral valve prolapse. Subsequent to service discharge, a VA examination conducted in September 1991, reported no recent episodes of dyspnea, orthopnea, precordial pain, or pedal edema. The apical impulse was in the fifth intercostal space, inside the midclavicular line. The rhythm was regular. There were no murmurs or thrills. An echocardiogram was normal. The diagnoses included history of mitral valve prolapse. A private medical record dated in October 1993, provided a clinical diagnosis of mitral valve prolapse. However, an echocardiogram conducted in February 1995, had normal findings. Private medical records in January 1996, reported a history of palpitations and mitral valve prolapse, however, the cardiac examination was within normal limits. Based on a review of the evidence of record, the Board finds that entitlement to service connection for mitral valve prolapse is not warranted. Although a clinical diagnosis of mitral valve prolapse was provided in 1993, the symptoms and basis upon which this diagnosis was made was not provided. Moreover, a subsequent echocardiogram was normal, with no evidence of mitral valve prolapse. The most recent examination conducted in 1996, reported only a history of mitral valve prolapse; however, the cardiac examination was normal. A diagnosis of a history of mitral prolapse, with otherwise negative clinical findings, does not equate to a diagnosis of a current mitral valve disability. Furthermore, there is no evidence of record of recent episodes of dyspnea, orthopnea, precordial pain, or pedal edema. Additionally, there is no evidence of record of mitral valve prolapse disease, to include mitral regurgitation, mitral valve thickening, or murmurs. As there is no current evidence of mitral valve prolapse confirmed by diagnostic tests, the claim of entitlement to service connection for mitral valve prolapse must be denied. D. Hypothyroidism Enlistment examinations dated in May 1975 and January 1982, did not report hypothyroidism. On the veteran's Officer Training School Commission examination dated in May 1983, there was no evidence of hypothyroidism. A metabolic screen, with a complete evaluation of thyroid function in August 1984, were within normal levels. In January 1988, it was noted that a thyroid battery was normal except for a thyroid-stimulating hormone test of 6.3; on retest the level was 5.2. In July 1989, the thyroid-stimulating hormone test was noted as high, reported at 7.3, with 7.0 at the high-end of the reference range. In October 1989 and January 1990, the veteran's thyroid laboratory tests were normal. A narrative summary dated in January 1990, reported that the veteran was hypothyroid since 1989, when she was started on medication. Thereafter, in August 1990 and May 1991, the veteran's thyroid laboratory tests were normal. Subsequent to service discharge, VA examinations conducted in August 1991, September 1991, and October 1991, reported a history of hypothyroidism, however, no clinical or laboratory findings were made as to this disorder. The veteran's thyroid laboratory tests were normal in November 1994 and April 1995. A VA examination conducted in March 1996, reported a history of hypothyroidism treated with medication. It was also noted that the medication was discontinued after a "couple of years." It was noted that the veteran's weight had not fluctuated "too much." The thyroid function tests were normal with the exception of the "TSH-HS" which was reported as high at 4.4, with the reference range up to 3.59. However, no diagnosis of hypothyroidism was made. In this case, no medical evidence has been presented or secured to render plausible a claim that the veteran currently has hypothyroidism. Accordingly, the Board concludes that the claim for service connection for hypothyroidism is not well grounded. 38 U.S.C.A. § 5107(a). E. Swollen Lymph Glands Service medical records reveal on examination in June 1982, shotty nodes of the left posterior cervical chain were found. In May 1984, the veteran had otitis, with reactive lymphadenopathy. On hospitalization in December 1984, the lymphatic examination was negative for adenopathy. In May 1985, the veteran complained of a sore throat with lesions. The initial examination found aphthous ulcers and lymphadenopathy with night sweats. Thereafter, an examination revealed bilateral tender anterior cervical adenopathy and inferiorly, with bilateral supraclavicular nodes. The impression was "viral syndrome/adenopathy." A chest x-ray was negative for abnormalities. A clinical entry dated in March 1986, reported complaints of intermittent tender lymph nodes around the neck, under the left arm, and the groin area. Based on the clinical finding of diffuse lymphadenopathy, a chest x-ray was conducted; findings included a normal chest. On follow-up examination the next month, a few shotty, tender cervical nodes were found. There was no tenderness in the supraclavicular area or arm. The diagnosis was lymphadenopathy of questionable etiology. A clinical entry dated in May 1986, reported a history of intermittent swollen glands in the neck. Examination revealed multiple small shotty nodes, both anterior and posterior to the cervical chain. The diagnosis was chronic lymphadenopathy, probably secondary to mouth and gum disease. Chronic adenopathy was diagnosed in May 1987. A hospital report dated in February 1988, gave a history of chronic cervical adenopathy for the past 2 to 3 years, with recurrent herpes simplex I stomatitis. Subsequent to service discharge, a VA outpatient treatment record dated in April 1993, reported no adenopathy. However, in November 1993, the veteran complained of swollen lymph nodes under her arms and in her groin area. The impression was bilateral axillary lymphadenitis. Although adenopathy was shown as chronic in service, swollen lymph nodes are symptoms rather than a disability from which the symptoms derive. As noted above, a claim for service connection requires the existence of a current disability. However, current medical evidence of an underlying impairment capable of causing the symptom alleged, in this case, swollen lymph nodes, is necessary to constitute plausible evidence of the existence of a current disability for VA service connection purposes. Therefore, the Board concludes that, because there is no evidence to render plausible that swollen lymph nodes is a separate and distinct disability in itself, no evidence has been presented or secured to render plausible a claim that swollen lymph nodes constitutes a "current disability" for the purposes of establishing a well grounded claim. Accordingly, the claim for service connection for swollen lymph nodes is not well grounded. 38 U.S.C.A. § 5107(a). F. Psychiatric Disorder Enlistment examinations dated in May 1975 and January 1982, did not report psychiatric abnormalities. On the veteran's Officer Training School Commission examination dated in May 1983, there is no evidence of a psychiatric disorder. A clinical entry dated in December 1986, noted that the veteran's father passed away, and she experienced an acute anxiety reaction. Thereafter, in October 1987, the veteran complained of an increase of stress and anxiety related to work. The diagnosis was "burnout" symptoms. In December 1987, the veteran complained of dizziness and syncope. The diagnoses included anxiety. In January 1988, a record of inpatient treatment included the diagnoses of occupational depression. On a psychiatric consultation conducted in February 1990, the diagnosis was psychiatric factors affecting physiological condition. Subsequent to service discharge, a mental health examination conducted in August 1991, found a somatization disorder, rule out an organic etiology. A VA examination conducted in October 1991, diagnosed obsessive, compulsive personality disorder. Private medical records reveal a diagnosis of anxiety in October 1993. Thereafter, in July 1994, it was noted that the veteran was experiencing a stressful situation at work; the diagnosis was anxiety/depression symptoms. In February 1995, it was noted that the veteran was prescribed Elavil for moderate depression. Although the veteran has been diagnosed with anxiety in October 1993, and was treated with medication for moderate depression in February 1995, there is no evidence that the veteran has a current psychiatric disorder related to service. There is no evidence of a chronic psychiatric disorder while in service. As there is no competent evidence that provides the required nexus between military service and any current psychiatric disorder, service connection for a psychiatric disorder is not warranted. See Caluza v. Brown, 7 Vet. App. 498 (1995). II. Increased Ratings Upon review of the record, the Board concludes that the veteran's claims for entitlement to initial evaluations in excess of 10 percent for fibromyositis, migraine headaches, and duodenal ulcers are well grounded within the meaning of the statute and judicial construction and the VA has fulfilled its duty to assist the veteran with these claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); 38 U.S.C.A. § 5107(a). Disability ratings are intended to compensate reductions in earning capacity as a result of the specific disorder. 38 C.F.R. Part 4 (1999). The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such disorder in civilian occupations. 38 U.S.C.A. § 1155. In considering the severity of a disability it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (1999). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; 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 concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board notes that these claims are based on the assignment of an initial rating for disabilities following an initial award of service connection for that disability. In Fenderson v. West, 12 Vet. App. 119 (1999), the United States Court of Appeals for Veterans Claims (hereinafter Court) held that the rule articulated in Francisco did not apply to the assignment of an initial rating for a disability following an initial award of service connection for that disability. Id.; Francisco, 7 Vet. App. at 58. Accordingly, the Board has recharacterized these issues on appeal in order to comply with the recent opinion by the Court in Fenderson. As in Fenderson, the RO in this case misidentified the issues on appeal as claims for increased disability ratings for the veteran's service-connected fibromyositis, migraine headaches, and duodenal ulcers, rather than as a disagreement with the original rating award for these disorders. However, the June 1992 statement of the case and the supplemental statements of the case have provided the veteran with the appropriate, applicable law and regulations and an adequate discussion of the bases for the RO's assignment of initial disability evaluations for the veteran's service-connected fibromyositis, migraine headaches, and duodenal ulcers. In addition, the veteran's pleadings herein clearly indicate that she is aware that her appeal involves the RO's assignment of initial disability evaluations. Consequently, the Board sees no prejudice to the veteran in recharacterizing these issues on appeal to properly reflect the veteran's disagreement with the initial disability evaluation assigned to her service-connected disorders. See Bernard v. Brown, 4 Vet. App. 384 (1993). A. Fibromyositis The veteran's service medical records reveal in December 1984, the veteran complained of muscle cramps in the legs and arms, mostly in the evenings. There was no fever, weakness, swelling, or arthralgias. The impression was muscle cramps unrelated to medication, without symptoms of systemic disease. In February 1985, the veteran complained of fatigue and weakness. The impression was fatigue, secondary to questionable anemia. In June 1986, the veteran stated that she was weak and weary, and had leg cramps. Her sensory and motor functions were intact, and there was no deficit except for weakness. She was able to move all limbs. The assessment was muscle weakness of questionable etiology. A narrative summary dated in January 1988, reported that the veteran had "multiple somewhat vague" complaints of chest pains, abdominal pains, and syncopal episodes, with complaints of dizziness and generalized fatigue. On hospitalization in January 1988, the veteran stated she felt weak with paresthesias of extremities, with possible palpitations, and would then pass out. She stated these spells began in 1984, but had increased to approximately once a week. She stated she would be able to ease herself down, and would not fall hard when she lost consciousness. After she regained consciousness, she stated she would feel weak, lethargic, and numb. On examination, extremities were without cyanosis, clubbing, or edema. Pulses were 2 plus throughout. A full maximal Bruce exercise tolerance test was negative. The diagnoses at discharge were healing peptic ulcers and mild mitral valve prolapse. In July 1988, a private neurological consultation noted complaints of cramping and aching in the distal upper and lower extremities for four years. The veteran stated that the aching was intermittent and deep in the muscles, particularly in the forearms and less in the calves, but at times was intense enough to prevent writing or walking for any length of time. These symptoms would appear for as long as several weeks and then spontaneously disappear, recurring two to three times a year; more recently recurring three to four times a year. On examination, vague tenderness in the forearms and distal calves of a minimal degree was found. Motor examination revealed normal bulk and tone with strength equal, without drift or fixation, with good heel and toe walking. Sensory examination was intact. Coordination was intact and gait was normal, with a negative Romberg. The impression was [e]vident distal myalgias intermittently recurring; one must exclude the possibility of an inflammatory, infectious, metabolic myopathy or early rheumatoid arthritis or lupus though all of these seem to be relatively unlikely. A more likely diagnosis may be early fibromyositis though the [veteran] does not have the sleep disorder often associated with the illness by her own account. In August 1988, the veteran complained of leg and lower back pain. The impression was muscular strain, questionable myositis, neuromuscular chemical deficiency, and multiple sclerosis. On follow-up, slight tenderness to palpation in both forearms was shown, with full range of motion and no edema. Neurological examination was intact, and strength was equal. The assessment was myalgias and weakness. In April 1989, the veteran complained of back pain, headache, and numbness in the hands and feet. The assessment was early fibromyositis. The veteran complained of fatigue and generalized weakness, especially in the extremities, with no specific pain in June 1989. The assessment was chronic fatigue/weakness. In July 1989, examination revealed full range of motion of the back with clear delineation, mild sacral tenderness, and muscle spasm lumbar region. Sensory and motor examination were within normal limits, without sensory deficits. Tandem walk was unsteady and gait was slow and deliberate. The assessment was left weakness and myalgias, possible fibromyositis, rule out multiple sclerosis and myelitis. In August 1989, the veteran complained of generalized myalgias. On examination, the extremities were not tender to palpation, with full range of motion. The assessment was generalized myalgias and fibromyositis. A narrative summary dated in January 1990, noted that the veteran complained of an increase in myalgias. She was having difficulty walking due to weakness and numbness in the extremities, legs worse than arms. She complained of occasional dizziness, and pain in her hips, knees, and wrists. On examination, it was noted that the veteran moved with an antalgic gait. The extremities revealed no edema and no joint hypertrophy. Neurologically, the veteran was weak in the lower extremities; however, the examiner noted that it was difficult to examine due to pain. Gross touch and deep tendon reflexes were equal, bilaterally. The impression was rule out multiple sclerosis. Upon laboratory results, the diagnoses were fibromyalgia, somatization tendencies, asymptomatic mitral valve prolapse, and hyperamylasemia. Subsequent to service discharge, a VA examination conducted in September 1991, reported the veteran gave a history of occasional pains in both hips, her fingers, and the lower back. She further stated she had an "achy" feeling in the muscles of the stomach area, legs, and arms. On examination, it was noted that the veteran walked without a limp and disrobed without pain, deformity, or loss of motor power. The cervical and dorsal spine had normal range of motion and contours. Lumbar flexion was limited to 75 degrees, and lateral bending in each direction was limited to 15 degrees. Examination of the upper extremities was within normal limits. The lower extremities were symmetrically equal in circumference and in leg length. The hips, knees, ankles, and feet had normal ranges of motion. The diagnoses included arthralgia of the hips and lumbar spine. X-rays of the lumbar spine and both hands were normal. A VA outpatient treatment record dated in April 1993, reported complaints of muscle inflammation and night sweats. The impression included night sweats, myalgias, and fatigue. A private medical record dated in October 1993, reported the veteran stated she had fibromyalgia. The assessment included fibromyalgia. In February 1995, the veteran complained of feeling exhausted, tiredness, weakness, body aches, night sweats, and occasional dizziness. Past diagnoses of fibromyalgia and mitral valve prolapse were noted. The diagnosis was viral syndrome. In April 1995, the veteran complained of fatigue and generalized body ache. The assessment was chronic fatigue syndrome versus possible mild adrenal insufficiency. In May 1995, the examiner stated that he suspected chronic fatigue, with only questionable fibromyositis, as there was a lack of typical tender points and there was a predominance of fatigue over pain. A VA neurology examination conducted in February 1996, found some tenderness with diminished range of motion and mobility, anteriorly, posteriorly, and laterally. Motor examination reported good strength without drift or atrophy. The tone was normal. The reflexes were 1 plus, and symmetric with no cortical release signs noted. Coordination was intact. The veteran's gait was reported as cautious but intact, with no dystaxia or dysmetria. She could walk tandem, without difficulty. The veteran's sensory examination was intact. The examiner reported that the veteran had a history of "so called" fibromyalgia with no "objection" (sic) findings. However, he concluded that as there were no objective findings, it was suggestive of a psychophysiologic process. A VA examination conducted in March 1996, reported that the veteran walked without difficulty. She was able to flex her lumbosacral spine 85 degrees, and extend backwards 30 degrees. Lateral flexion was to 45 degrees and rotation was to 30 degrees. The veteran could squat without problems. Examination of the paraspinal muscles revealed vague tenderness over the sacroiliac area. In the horizontal position, the veteran was able to flex the hips to 120 degrees and abduct to 40 degrees. The veteran complained of pain during these motions. The clinical diagnoses included low back syndrome, associated with fibromyalgia, rule out degenerative changes of both hip areas. X-rays of the hips and lumbosacral spine were negative. Private medical records dated in July 1996 and February 1997 , reported complaints of lethargy, weakness, and tiredness. The diagnosis was chronic fatigue syndrome. A report from the veteran's private physician dated in December 1998, included chronic fatigue syndrome and "fibromylagia" (sic) disease as diagnoses. A VA examination conducted in April 1999, showed the range of motion of the veteran's shoulders, elbows, wrists, hips, knees, and ankles were all within normal limits and symmetrical. There was no atrophy of any muscle group, nor was there muscle weakness. She had good heel and toe rising and she was able to fully squat. She had full abduction, and internal and external rotation of the hips. She was able to flex her hips and knees to their fullest and normal range. The examiner concluded that the veteran's real problem was joints rather than muscle. I do not believe the diagnosis of fibromyositis is appropriate, however, I do feel that [the veteran] probably has a polyarthralgia rheumatica especially since she has responded to cortisone medications to such a great degree. A neurology examination conducted at this time, found good motor strength and tone was normal. Reflexes were 1 plus, and symmetric. Plantars were flexor, with no cortical release signs found. Coordination in the upper and lower limbs were intact. The veteran's gait, including tandem, was normal. The sensory examination was intact to all modalities. The diagnostic impression included a history of "so called" fibromyositis without evidence of any other significant neurological problems. The veteran's service-connected fibromyositis of the hips and lumbosacral spine is rated as 10 percent disabling under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5021. This rating is based on limitation of motion of the affected part. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (1999). Slight limitation of motion of the lumbar spine warrants a 10 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (1999). A 20 percent rating is for assignment for moderate limitation of motion of the lumbar spine, and a 40 percent disability rating is warranted when severe limitation of motion of the lumbar spine is shown. Id. Hip flexion from 0 to 125 degrees and hip abduction to 45 degrees is considered normal. 38 C.F.R. § 4.71, Plate II (1999). When there is limitation of flexion of the thigh to 45 degrees, a 10 percent evaluation is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Limitation of flexion of the thigh to 30 degrees warrants a 20 percent evaluation, and limitation of flexion of the thigh to 20 degrees warrants a 30 percent evaluation. Id. Flexion limited to 10 degrees is rated 40 percent. Id. Additionally, limitation of thigh rotation, with the loss of the ability to toe out more than 15 degrees, or for limitation of adduction with the loss of the ability to cross the legs warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5253 (1999). A 20 percent evaluation requires limitation of abduction with motion loss beyond 10 degrees. Id. Limitation of thigh extension to 5 degrees also warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5251 (1999). The evidence of record contemporaneous with the initial rating decision reveals that the veteran had slight limitation of motion of the lumbar spine. Normal range of motion at both hips were noted. Accordingly, a 10 percent disability rating for fibromyositis for the lumbosacral spine and hips was proper. The RO granted service connection and assigned the 10 percent evaluation for fibromyositis as of the day following separation from active service, i.e., June 28, 1991. See 38 C.F.R. § 3.400(b)(2)(i) (1999). After review of the evidence, there is no medical evidence of record that would support a rating in excess of 10 percent for this disability at any time subsequent to the day following separation from active service, i.e., June 28, 1991. Id.; Fenderson v. West, 12 Vet. App. 119 (1999). Although limitation of the hips was shown in March 1996, it does not meet the criteria for a separate 10 percent evaluation. B. Duodenal Ulcer The veteran's service medical records reveal that an esophagogastroduodenoscopy indicated several duodenal erosions and healing ulcers. Thereafter, in April 1988, an upper gastrointestinal series revealed duodenitis. Subsequent to service discharge, VA outpatient treatment records report a history of peptic ulcer disease. In 1991, the veteran complained of abdominal pain, bloating, and intolerance to certain foods. A VA examination conducted in March 1996, reported that the veteran's weight does not fluctuate "too much." She had recurrent episodes of peptic ulcer disease since service, and had taken Zantac. The veteran was not anemic and did not vomit, and was without a history of hematemesis or melena. The veteran stated that she had constant pain in her upper abdomen. On examination, the abdomen was soft, with a slight tenderness, but no mass felt in the upper abdomen. The clinical diagnoses included a history compatible with peptic ulcer disease and irritable bowel syndrome. An upper gastrointestinal series and small bowel series was negative for abnormalities. A kidney, ureter, and bladder series found evidence of a previous surgery in the medial aspect of the left upper quadrant, otherwise, the examination of the abdomen was negative. A fluoroscopic and radiographic examination of the esophagus was negative for abnormalities. Private medical records reveal a clinical assessment of anemia. In December 1995, the veteran complained of recurrent abdominal pain and diarrhea. In January 1996, the veteran complained of abdominal discomfort for 4 months. It was noted that she took Tagamet with intermittent relief. On examination, the veteran appeared well nourished and well developed. There was no hepatosplenomegaly, masses, or tenderness. The rectal examination showed no masses or tenderness. The hemoccult was negative. The diagnosis was irritable bowel syndrome. In December 1998, the veteran complained of tenderness in the right upper quadrant. The diagnosis was epigastric pain. A gallbladder sonogram was unremarkable. A sonogram of the pancreas noted that the head and the tail of the pancreas were obscured by the bowel gas, but that the body of the pancreas was unremarkable in appearance. A VA examination conducted in April 1996, noted that the veteran was not taking any nonsteroidal anti-inflammatory medications. The veteran reported intermittent attacks of abdominal pain, characterized as a deep, burning sensation in the left upper quadrant. The pain was noted as gradual that lasted for hours, and improved with food. It was noted that the veteran took medication for her symptoms approximately 2 to 3 times a week which provided some relief. There were no complaints of significant nausea, vomiting, constipation, or diarrhea, and no history of anemia. The diagnosis was duodenal inflammation, either duodenal ulcer or duodenitis. The examiner stated that the veteran was not markedly disabled or incapacitated by this disorder, but it represented "some degree of a problem for her." The veteran's duodenal ulcer disorder is rated as 10 percent disabling under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7305. This rating contemplates duodenal ulcer productive of mild impairment, with recurring symptoms once or twice yearly. Id. A 20 percent disability rating is warranted when there is evidence of moderate impairment, with recurrent episodes of severe symptoms 2 or 3 times a year averaging 10 days in duration or with continuous moderate manifestations. Id. A 40 percent rating is to be assigned when the ulcers are moderately severe, with impairment of health manifested by anemia and weight loss or recurring incapacitating episodes averaging 10 days or more in duration at least four or more times a year. Id. In the instant case, there is no evidence of record which shows continuous moderate manifestations or recurrent episodes of severe symptoms 2 or 3 times a year averaging 10 days in duration as required for a 20 percent disability rating. Although the veteran has reported intermittent attacks of abdominal pain, they are not characterized as manifested by severe symptoms. There were no complaints of significant nausea, vomiting, constipation, or diarrhea, and no history of anemia. The medical records show no active ulcer. Additionally, although the veteran has been diagnosed with irritable bowel syndrome, an initial evaluation in excess of 10 percent under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7319 (1999) is also not for assignment. A 30 percent evaluation is warranted when there is severe impairment with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. Id. The veteran's irritable bowel syndrome is not shown to be severe, as weight loss and anemia has not been shown. Additionally, although she complains of diarrhea, constipation has not been shown and abdominal distress has been shown to be only intermittent. Additionally, the most recent examiner concluded that the veteran was not markedly disabled or incapacitated by her gastrointestinal disorder. In this case, the RO granted service connection and originally assigned a 10 percent evaluation for duodenal ulcers as of the day following separation from active service, i.e., June 28, 1991. See 38 C.F.R. § 3.400(b)(2)(i) (1999). After review of the evidence, there is no medical evidence of record that would support a rating in excess of 10 percent for this disability at any time subsequent to the day following separation from active service, i.e., June 28, 1991. Id.; Fenderson v. West, 12 Vet. App. 119 (1999). C. Migraine Headaches The veteran's service medical records reveal numerous complaints and findings of migraines. Subsequent to service discharge, a VA outpatient treatment record dated in August 1991, reported complaints of headaches that had become more persistent. In September 1991, the headaches were described as bilateral pressure in the occipital region that lasted several hours. In December 1991, she reported complaints of frequent headaches. In April 1993, the veteran complained of a dull headache of three months duration. There was no blurred vision or paresthesia. A VA neurologic examination was conducted in February 1996. The veteran reported that her migraines were associated with nausea, photophobia, and hypercasia that would last several hours to days, usually in a period of time before her menses. The examiner concluded that the veteran had a history of a chronic migraine syndrome, which "sounds more like chronic vascular tension headache difficulty." A VA examination conducted in April 1999, reported that the veteran had migraines that occurred once a month "or more" with nausea, hyperacusis, and photophobia that lasted up to several days. The veteran stated that the headaches required her to be off work for two days. There was no confusion, disorientation, speech difficulties, weakness, numbness, or vomiting associated with the headaches. The examiner's conclusion was classic migraine syndrome, with severe headaches which were only partially controlled with medication that could be incapacitating for several days a month. The veteran's migraines are assigned a 10 percent disability rating under the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8100. This rating contemplates migraine headaches, with characteristic prostrating attacks averaging one in 2 months over several months. Id. A 30 percent disability rating is warranted with characteristic prostrating attacks occurring on an average of one a month over the last several months. Id. A 50 percent evaluation, the highest possible rating under Diagnostic Code 8100, is warranted with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Id. In sum, the applicable rating criteria link the ratings for migraine headaches to two elements: severity and frequency. It is not sufficient to demonstrate the existence of a particular frequency of headaches; the headaches must be of a specific prostrating character. The Board finds that the veteran's service-connected migraines warrant a 30 percent disability rating. The evidence of record shows that the veteran's headaches occur approximately once a month, usually around the time of her menses, and result in incapacitating symptoms such as nausea, photophobia, and hypercasia that last up to several days. The veteran has reported that she usually misses work two days a month due to these symptoms. In this case, the RO granted service connection and originally assigned a 10 percent evaluation for migraines as of the day following separation from active service, i.e., June 28, 1991. See 38 C.F.R. § 3.400(b)(2)(i) (1999). By this decision, the Board has granted an initial disability evaluation of 30 percent for the veteran's service-connected migraine headaches. After review of the evidence, there is no medical evidence of record that would support a rating in excess of 30 percent for this disability at any time subsequent to the day following separation from active service, i.e., June 28, 1991. Id.; Fenderson v. West, 12 Vet. App. 119 (1999). Very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability have not been shown at any time by the record. Accordingly, an initial disability evaluation of 30 percent, but no more, is warranted. ORDER The claims of entitlement to service connection for disorder manifested by leg cramps, residuals of a left adrenalectomy, hypothyroidism, and mitral valve prolapse are denied. Entitlement to an initial disability evaluation in excess of 10 percent for fibromyositis is denied. Entitlement to an initial disability evaluation in excess of 10 percent for duodenal ulcers is denied. Entitlement to an initial disability evaluation of 30 percent for migraine headaches is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND On the veteran's Application for Compensation or Pension, received in October 1991, she claimed entitlement to service connection for auritis. The veteran stated that she had this disorder in service in September 1984. The RO developed this claim as "auritis, manifested as leg cramps." Auris is a synonym for ear. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 169 (26th Ed. 1974). Although the RO indicated in the rating decision dated in February 1992, that there were no complaints of ear pain in service, the veteran's service medical records reveal that in May 1984, the veteran complained of a left ear ache. The assessment was left otitis media with questionable external otitis. In September 1984, the clinical records indicate that the veteran had been hospitalized for acute labyrinthitis. She complained of a "stuffy feeling" in the ears and congestion. The diagnosis was rule out viral labyrinthitis. VA outpatient treatment records in 1991, reported complaints of stuffiness in the ears. Private medical records dated in March 1995, report an early stage of Meniere's syndrome. The Board is of the opinion that the veteran in filing her claim for entitlement to service connection for "auritis" in 1991, was claiming a separate claim of entitlement to service connection for an ear disorder, rather than a disorder manifested as leg cramps. Accordingly, the RO should readjudicate the issue of entitlement to service connection for auritis, a disorder of the ear. 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 United States Court of Appeals for Veterans Claims 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, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the regional offices 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. No action is required by the veteran until she receives further notice; however, she may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). JOY A. MCDONALD Acting Member, Board of Veterans' Appeals