Citation Nr: 0001544 Decision Date: 01/19/00 Archive Date: 01/28/00 DOCKET NO. 97-18 365 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a neck disability. 2. Entitlement to service connection for a back disability. 3. Entitlement to service connection for disability of the knees and legs. 4. Entitlement to service connection for disability of the feet. 5. Entitlement to service connection for diabetes mellitus. 6. Entitlement to service connection for migraine headaches. 7. Entitlement to service connection for hearing loss. 8. Entitlement to an increased disability rating for hypertension, currently rated as 20 percent disabling. 9. Entitlement to an increased disability rating for skin disorders, including tinea pedis and xerosis, currently rated as 10 percent disabling. 10. Entitlement to an increased disability rating for maxillary sinusitis, currently rated as 10 percent disabling. [The Board has issued a separate decision on the issue of entitlement to a program of vocational rehabilitation]. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The veteran served on active duty from July 1975 to July 1995. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the Wichita, Kansas, Regional Office (RO) of the United States Department of Veterans Affairs (VA). The RO denied service connection for a neck disability, a back disability, disability of the legs and knees, disability of the feet, diabetes mellitus, migraine headaches, and hearing loss. The veteran also appealed the disability ratings initially assigned for his service-connected hypertension, skin disorder, and maxillary sinusitis. The RO has increased the ratings for each of those disabilities, and the veteran has continued his appeal, seeking ratings higher than the current ratings. The veteran also has appealed the issue of entitlement, under Chapter 31, Title 38 of the United States Code, to a program of vocational rehabilitation. That issue is addressed in a separate Board decision. FINDINGS OF FACT 1. VA medical records have provided diagnoses of possible or probable myofascial pain syndrome or degenerative joint disease in the veteran's neck. 2. The veteran sought treatment during service for neck pain. 3. The service and VA medical records provide evidence of possible degenerative joint disease of the cervical spine beginning during service and continuing after service. 4. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeals for service connection for a back disability, disability of the feet, and hearing loss, and for increased ratings for hypertension and skin disorders. 5. The veteran received treatment during service for low back strain following a motor vehicle accident. 6. The veteran received treatment for mechanical low back pain shortly before separation from service. 7. VA examination in 1996 revealed limitation of motion of the lumbar spine with pain on motion. 8. The veteran was treated for bilateral knee pain during service, with diagnoses of patellofemoral pain syndrome and tendonitis. 9. The veteran has received treatment for bilateral knee pain since service, with diagnoses of osteoarthritis and retropatellar pain syndrome. 10. No disorder of the feet was noted when the veteran was examined in 1975 for entrance into service. 11. The veteran was diagnosed with bilateral pes planus in 1985, and on several additional occasions during and since service. 12. Laboratory tests made during the veteran's service revealed borderline or high fasting blood glucose levels on some occasions. 13. In 1998, a physician indicated that it was possible that the veteran had diabetes mellitus. 14. The veteran has not submitted a medical diagnosis or other competent medical evidence that he has migraine headaches. 15. The veteran has disabling left ear hearing loss that began during service. 16. The veteran does not have disabling impairment of the hearing in his right ear. 17. The veteran has hypertension treated by medication, with diastolic pressure predominantly less than 120. 18. The veteran's skin disorders are currently manifested by dryness and lesions affecting the scalp, neck, and face, and sometimes back, arms, hands, and feet, with constant itching. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for a neck disability is well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. Low back strain with limitation of motion was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 3. The claim of entitlement to service connection for disability of the knees is well grounded. 38 U.S.C.A. § 5107 (West 1991). 4. Bilateral pes planus was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 5. The claim of entitlement to service connection for diabetes mellitus is well grounded. 38 U.S.C.A. § 5107 (West 1991). 6. The claim of entitlement to service connection for migraine headaches is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 7. Left ear hearing loss was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.385 (1999). 8. The veteran does not have right ear hearing loss. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.385 (1999). 9. The criteria for a disability rating in excess of 20 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.2, 4.7, 4.10, 4.104, Diagnostic Code 7101 (1999). 10. The criteria for a 30 percent disability rating for skin disorders, including tinea pedis and xerosis, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.2, 4.7, 4.10, 4.118, Diagnostic Code 7806 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Well Grounded Claim Requirement The veteran is seeking service connection for several disorders, and increased ratings for several disabilities that have already been found to be service-connected. A person who submits a claim for veteran's benefits has 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) (West 1991). The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter "CAVC") has defined a well grounded claim as a plausible claim; one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). When a veteran has presented a well grounded claim within the meaning of 38 U.S.C.A. § 5107(a) (West 1991), VA has a duty to assist the veteran in the development of his claim. 38 U.S.C.A. § 5107(a) (West 1991). In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit (hereinafter "Federal Circuit") held that, under 38 U.S.C.A. § 5107(a), VA has a duty to assist only those claimants who have established well grounded claims. More recently, CAVC issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Service Connection Claims Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). In order for a claim for service connection to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Epps, 126 F.3d at 1468; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). Where the determinative issue involves medical causation or etiology, or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Epps, 126 F.3d at 1468. Further, in determining whether a claim is well-grounded, the supporting evidence is presumed to be true and is not subject to weighing. King v. Brown, 5 Vet.App. 19, 21 (1993). In regard to establishing a well-grounded service connection claim, the second and third Epps and Caluza elements (incurrence and nexus evidence) can also be satisfied under 38 C.F.R. § 3.303(b) (1999) by (1) evidence that a condition was "noted" during service or during an applicable presumption period; (2) evidence showing post-service continuity of symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage, 10 Vet. App. at 496. Moreover, a condition "noted during service" does not require any type of special or written documentation, such as being recorded in an examination report, either contemporaneous to service or otherwise, for purposes of showing that the condition was observed during service or during the presumption period. Id. at 496-97. However, medical evidence is required to demonstrate a relationship between the present disability and the demonstrated continuity of symptomatology unless such a relationship is one as to which a lay person's observation is competent. Id. at 497. In the case of a disease only, service connection also may be established under section 3.303(b) by (1) evidence of the existence of a chronic disease in service or of a disease, eligible for presumptive service connection pursuant to statute or regulation, during the applicable presumption period; and (2) present disability from it. Savage, 10 Vet. App. at 495. Either evidence contemporaneous with service or the presumption period or evidence that is post service or post presumption period may suffice. Id. Neck The veteran contends that he has neck pains that began during service. His service medical records include a report indicating that x-rays taken of his cervical spine in May 1979 showed no significant abnormalities. In May 1987, the veteran reported pain in the right side of his neck that had been present for a week. He reported that the pain started under his right eye and extended down the right side of his face, jaw, and neck. The examiner noted tenderness along the muscles. There was full range of motion of the neck. The examiner's impression was a possible viral illness. Outpatient treatment notes from July 1995 reflect that the veteran reported a history of episodes of joint pains. He reported that he presently had pain in both knees, the left side of his back, and his right shoulder. The examiner's assessment was probable degenerative joint disease, with Lyme disease or other disorders to be ruled out. After service, in August 1995, the veteran sought VA outpatient treatment for migratory arthralgias and joint pains. He reported a three to four month history of intermittent pain in his left knee, right shoulder, and neck region. The examiner found that the veteran had full range of motion of the spine and bilateral upper extremities. The veteran had tenderness in trigger points along the right trapezius, supraspinatus, and infraspinatus muscles. The examiner's assessment was probable myofascial pain syndrome. The examiner prescribed physical therapy and medication. VA physical therapy notes from September 1995 listed an assessment of cervical degenerative joint disease. In October 1995, physical therapy notes listed an assessment of resolving cervical strain. In his October 1996 notice of disagreement, the veteran reported that he had received treatment during service for musculoskeletal problems, including neck pains. He reported that since service he had received physical therapy and medication for continuing problems. On VA medical examination in November 1996, the veteran reported having problems with his back and neck since the late 1970s. He reported that in the last three years he had had occasional episodes where the pain was so severe that he could not get out of bed. He reported that during the episodes of severe pain he also had nausea. The examiner found that the musculature of the veteran's back was normal, and that there were no postural abnormalities. X-rays of the cervical spine showed no evidence of fracture, dislocation, or destruction. Interspaces and foraminal contour were satisfactorily maintained. There was some straightening of the normal lordotic curve. The examiner found that x-rays of the cervical spine were basically normal. In letters dated in July 1997 and June 1999, the veteran's wife wrote that she had observed that the veteran had a lot of pain in his legs, knees, feet, back, and neck. In a July 1997 hearing at the RO, the veteran reported that he sought treatment many times during service for pain in his feet, knees, ankles, legs, back, and neck. He reported that the chronic pain had made him unable to exercise and run as he previously had. In June 1999, the veteran had a travel board hearing at the Wichita RO before the undersigned Member of the Board. The veteran reported that he had treatment during service for pain in his feet, knees, legs, and back. He reported that since service he had received physical therapy and medication from a VA facility for musculoskeletal pains. He reported that he had cracking in his neck when he moved it. He stated that he believed that some of the headaches that he had resulted from discomfort in his neck. He reported that one of the doctors that he saw during service told him that pain in his neck could result from problems with his feet, knees, and legs. The veteran's claim is supported by a medical diagnosis of a current disability, as VA outpatient treatment records include diagnoses of myofascial pain syndrome and degenerative joint disease of the cervical spine. The service medical records provide evidence that the veteran reported neck pains during service, and that one examiner reported that the veteran might have degenerative joint disease. As there is evidence of possible degenerative joint disease of the cervical spine during service, and evidence of neck pain continuing after service, the Board finds that the veteran's claim for service connection for a neck disability is a well grounded claim. Because the claim is well grounded, VA has a duty to assist the veteran in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991). In this case, service and VA medical records include findings of a possible muscular disorder or possible degenerative joint disease. X-rays taken on VA examination in November 1996, however, did not show degenerative joint disease of the cervical spine. The Board finds that additional medical evidence and opinion should be developed regarding the nature of the current condition of the veteran's neck, and any relationship between any current disorder and service. The additional evidentiary development will be addressed in a remand that follows the decisions on the issues on appeal. Back The veteran contends that he has back pain that began during service. His service medical records reflect that he was seen in August 1975 for pain in his back and left arm, after he fell while exercising. The examiner noted muscle spasms in the veteran's left lower back. In May 1982, he was seen for low back pain following a motor vehicle accident. The examining physician noted that the veteran's left lumbar paraspinatus muscles were tender and tense. Motor and sensory functions and deep tendon reflexes in the legs were intact. The examiner's assessment was acute low back strain. In April 1995, the veteran was seen for low back pain of two weeks duration. The examiner noted that the veteran's back had a full range of motion, with no point tenderness. Neurological signs were grossly normal. There was a slight decrease in lordosis. The examiner's impression was mechanical low back pain. Outpatient treatment notes from July 1995 reflect that the veteran reported a history of episodes of joint pains. He reported that he presently had pain in both knees, the left side of his back, and his right shoulder. The examiner's assessment was probable degenerative joint disease, with Lyme disease or other disorders to be ruled out. After service, the veteran had VA outpatient treatment in August through October 1995 for musculoskeletal pain. At that time, he reported pain in his lower extremities and in his shoulder and neck areas. In his October 1996 notice of disagreement, the veteran reported that he had received treatment during service for musculoskeletal problems, including back pain. He reported that since service he had received physical therapy and medication for continuing problems. On VA medical examination in November 1996, the veteran reported having problems with his back and neck since the late 1970s. He reported that in the last three years he had had occasional episodes where the pain was so severe that he could not get out of bed. He reported that during the episodes of severe pain he also had nausea. The examiner found that the musculature of the veteran's back was normal. On examination, the veteran could move his lower back to 80 degrees of flexion, with mild pain in the right lower back. He had 15 degrees of extension, with a dull ache in the center of the back. He had 30 degrees of left lateral bending, without pain, and 20 degrees of right lateral bending, with mild pain in the center of the right lower back. He had rotation to the left to 40 degrees, with moderate pain in the left middle back, and to the right to 45 degrees, with mild pain in the right middle back. X-rays of the lumbar spine and the thoracic spine were normal, without evidence of fracture, deformity, or arthritis. The examiner's diagnosis was low back pain. In a May 1997, the veteran reported that he continued to experience significant pain in many of his joints, including his back, when the back or other joints were in motion. In letters dated in July 1997 and June 1999, the veteran's wife wrote that she had observed that the veteran had a lot of pain in his legs, knees, feet, back, and neck. In a July 1997 hearing at the RO, the veteran reported that he sought treatment many times during service for pain in his feet, knees, ankles, legs, back, and neck. He reported that the chronic pain had made him unable to exercise and run as he previously had. He reported that he had pain in his back one or two times per week, aggravated by sitting or staying in one position for long periods. In his June 1999 travel board hearing, the veteran reported that he had treatment during service for pain in his feet, knees, legs, and back. He reported that since service he had received physical therapy and medication from a VA facility for musculoskeletal pains. He reported that he had periods of intense low back pain, accompanied by nausea, lasting from fifteen minutes to two hours. The veteran was treated for low back pain on a number of occasions during service, including treatment for low back strain following a motor vehicle accident. He has reported that intermittent low back pain continued after service. VA examination in 1996 revealed limitation of motion of the lumbar spine, with pain on motion. The Board finds that the evidence of a low back injury during service and symptoms continuing after service is sufficient to form a well grounded claim for service connection. In addition, the Board finds that the facts relevant to the veteran's claim for service connection for a back disability have been properly developed, such that VA has satisfied its statutory obligation to assist the veteran in the development of that claim. While the low back strain diagnosed after the veteran's 1982 motor vehicle accident was described as acute, service medical records reflect that the veteran had low back pain in 1995, not long before his separation from service. The 1996 VA examination produced evidence of limitation of motion and pain on motion of the low back. Overall, the Board finds that the evidence reasonably shows that a low back disorder was present during service, and continued after service. Therefore, the Board grants service connection for low back strain with limitation of motion. Knees and Legs The veteran contends that he has pain in his knees and legs that began during service. The veteran is already service- connected for residuals of a fracture of the left tibia. The present claim for service connection for disability of the knees and legs involves disorders other than that fracture. No disorder of the lower extremities was noted when the veteran was examined in July 1975 for entry into service. During service, the veteran was seen on a number of occasions for bilateral knee pain. In April 1977, he reported intermittent pain in his knees since December 1976. The examiner found that the veteran had full range of motion in both knees. The veteran underwent physical therapy in April and May 1977. X-rays taken in April 1977 reportedly showed a bipartite patella in the right knee. In November 1978, he reported intermittent pain in both knees, and he was given pain medication. In June 1979, he reported pain in both knees and a slight feeling of locking of the left knee. The examiner found that the right knee was stable, but that the left knee had a slight anterior drawer sign and a slight anterior laxity of the lateral collateral ligament. In 1983, the veteran sustained a stress fracture in the distal shaft of his left tibia. In December 1985, the veteran was seen for pain in his left knee and right shin. The veteran reported that he ran two miles per day. An orthopedist found that the veteran had patellofemoral joint syndrome in his left knee, with recurrent exacerbations. He was referred to a podiatrist to obtain orthotics, as it was noted that he had abnormal wear on his shoes. The podiatrist noted that the veteran had bilateral pes planus with everted heel position. The podiatrist wrote that the veteran's left knee pain might be aggravated by excessive pedal pronation. In December 1993, the veteran was seen for pain in both knees after running. The veteran reported that he ran three to four miles, four to five times per week. The examiner found a full range of motion in the veteran's knees, with no crepitus, swelling, or effusion. There was no joint laxity. The examiner noted bilateral flat feet, and a varus deformity of the lower legs, greater in the right than in the left. The examiner's assessment was probable quadriceps tendonitis, secondary to overuse and anatomical variation. Outpatient treatment notes from July 1995 reflect that the veteran reported a history of episodes of joint pains. He reported that he presently had pain in both knees, the left side of his back, and his right shoulder. The examiner's assessment was probable degenerative joint disease, with Lyme disease or other disorders to be ruled out. After service, in August 1995, the veteran sought VA outpatient treatment for migratory arthralgias and joint pains. He reported a three to four month history of intermittent pain and stiffness in his left knee, right shoulder, and neck region. The examiner found that the veteran's knees had full range of motion and no swelling. The examiner's assessment was probable myofascial pain syndrome. On VA medical examination in November 1996, the veteran reported that he had had problems with his knees for more than twenty years, and that he had episodes of pain, stiffness, and locking in his knees and ankles, particularly with prolonged activity. The examiner found no swelling or deformity in the veteran's knees or ankles, and no subluxation or instability of the knees. The range of motion of the knees was to 110 degrees of flexion in each knee, with aching in the knee, and to 0 degrees of extension. The ranges of motion of the ankles were to 45 degrees of plantar flexion bilaterally, 15 degrees of dorsiflexion in the left ankle and 20 degrees in the right, 30 degrees of inversion bilaterally and 5 degrees of eversion bilaterally. There was no pain on motion of the ankles noted. X-rays of the knees showed no evidence of acute fracture or dislocation. There was a bipartite patella on the right. X-rays of the ankles were normal. The examiner's impression was a bipartite right patella, but otherwise normal knees, without indication of degenerative joint disease, and normal ankles based on examination and x-rays. In May 1997, the veteran reported that he continued to have pain in his knees with motion. In a July 1997 letter, the veteran's wife wrote that the veteran had a great deal of pain in his legs, knees, feet, back, and neck. She wrote that she had to help him get up from a sitting position, because his knees and legs hurt. She reported that she had seen the veteran wincing when he walked. In a July 1997 hearing at the RO, the veteran reported that he had problems with his legs, knees, and feet from 1975, the first year that he was on active duty. He reported that he had once been able to run five miles, and that his problems had worsened to the point that he could no longer run more than one eighth of a mile. In October 1997, the veteran wrote that he did not have chronic knee problems when he entered service. He wrote that after several years of service and repeated treatment doctors had diagnosed knee syndromes that had continued through the present. VA outpatient treatment notes from September 1998 reflect the veteran reported pain in his left knee, and stiffness in both knees after prolonged periods of inactivity. The examiner noted that the veteran had full range of motion in his knees, without locking or instability. There was mild crepitus in the retropatellar region upon compression. The examiner's diagnosis was osteoarthritis of both knees, and retropatellar pain syndrome. In March 1999, he was seen for continued pain in both knees, worse in the left. He reported sensations of grinding and occasional catching of the left kneecap. The examiner found that both knees had full ranges of motion. There was retropatellar crepitus bilaterally, worse in the left knee. Both knees were stable to valgus and varus stress. The examiner continued the diagnosis of osteoarthritis and retropatellar pain syndrome. In June 1999, the veteran's wife wrote that she had seen the veteran have problems walking because of pain in his feet and knees. In his June 1999 travel board hearing, the veteran reported that he was first treated for knee problems in 1977 or 1978, and that a doctor found that he had a patellofemoral problem. He reported that he continued to have occasional locking in his knees. He reported that he had stiffness in his knees after extended sitting. Recent outpatient treatment notes include diagnoses of osteoarthritis and retropatellar pain syndrome. The veteran was seen for bilateral knee pain during service, with diagnoses including tendonitis and patellofemoral joint syndrome. The treatment notes during and after service provide evidence of continuity of symptoms. The Board finds that the evidence is sufficient to form a well grounded claim for service connection for disability of the knees. When all of the evidence is considered, there is apparent conflict regarding the condition of the veteran's knees since service. Treatment notes from 1998 and 1999 provide diagnoses of osteoarthritis and retropatellar pain syndrome, but the report of a 1996 examination indicated that the veteran did not have arthritis or any other disorder of the knees except for a bipartite right patella. An additional examination should be performed to clarify the nature and etiology of any current disorder affecting the veteran's knees. The remand instructions will follow the decisions on the other issues on appeal. Feet The veteran contends that he has bilateral foot pain due to pes planus. He contends that his pes planus first arose during service, and not prior to service. A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted at entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. §§ 1111, 1137 (West 1991); 38 C.F.R. § 3.304(b) (1999). When the veteran was examined in July 1975 for entrance into service, his feet were found to be normal, with no notation of flat feet or any other disorder. In May 1981, the veteran was seen for pain in his right great toe with plantar flexion. The examiner noted slight tenderness, with no edema or effusion. The examiner's impression was possible tendonitis. In a December 1985 podiatry consultation, it was noted that the veteran had patello-femoral joint syndrome in his left knee, and that he had abnormal wear on his shoes with running. The examining podiatrist found that the veteran had bilateral pes planus, with everted heel position bilaterally. The podiatrist wrote that the veteran's left knee pain might be aggravated by excessive pedal pronation. In January and February 1986, the veteran was fitted for and provided with orthotics. Medical records show that a plantar nevus was removed from the veteran's right foot in May 1987. Treatment notes from December 1990 indicate that the veteran had flat feet, described as mild and asymptomatic. Outpatient treatment notes from December 1993 also indicate that the veteran had bilateral flat feet. In April 1995, the veteran was noted to have pes planus, and a thickened, cracked nail on the right fourth toe. On VA medication examination in November 1996, the examiner found that the veteran's feet had normal appearance and function, with no deformity. Since his retirement from service, the veteran has obtained some medical treatment at a military facility. Treatment notes from May 1997 reflect that the veteran reported mid-foot pain while running. He reported that he had a long history of pes planus, and that he used orthotics. The examiner found that the veteran had bilateral pes planus, without acute bony tenderness. In July 1997, he again reported pain in his feet, and he was again noted to have bilateral pes planus. In September 1998, the veteran was seen for left knee pain and the return of left foot pain. The examiner found that the veteran had plantar fasciitis secondary to chronic pes planus. In a July 1997 hearing at the RO, the veteran reported that he was first diagnosed with pes planus in approximately 1986, and that a service physician had him fitted with orthotics. He reported that he was currently having pain in his feet daily. In a July 1997 letter, the veteran's wife noted that the veteran had a lot of pain in his feet, as well as his legs, knees, neck and back. She reported that she had seen him wince when he walked. She stated that he wore inserts in his shoes, but that he still had trouble walking. In September 1997, podiatrist Pierre G. Desrosiers, D.P.M., wrote that he was treating the veteran for foot pain. Dr. Desrosiers wrote that the veteran had bilateral pes planus. Dr. Desrosiers expressed the opinion that a service medical record notation in 1985 that the veteran had bilateral pes planus was the first indication of his pes planus. In September 1998, Bryan L. Smith, M.D., wrote that he had been the veteran's primary care physician at the health clinic at Fort Leavenworth since 1995. Dr. Smith also expressed the opinion that notations of the veteran's pes planus in 1985 were the first indication that he had pes planus. In written statements submitted in 1998, the veteran asserted that his bilateral pes planus began during service. He noted that pes planus was not noted when he was examined for entrance into service, and that he was first diagnosed with pes planus in 1986. In June 1999, the veteran's wife wrote that the veteran could no longer run as he had in the past, and that he had trouble walking because of pain in his feet and knees. In his June 1999 travel board hearing, the veteran reported that he began to have problems with his feet in approximately 1986, and he was diagnosed with flat feet. He reported that orthotics were made for him to help with that condition. He reported that he continued to have pain in his feet with walking. The evidence includes a current diagnosis of bilateral pes planus, diagnosis of that condition during service, and medical opinion linking the condition to service. Therefore, the Board finds that the veteran has submitted a well grounded claim for service connection for bilateral pes planus. The Board also finds that the facts relevant to that claim have been properly developed, such that VA has satisfied its statutory obligation to assist the veteran in the development of that claim. The veteran was not found to have flat feet when he was examined for entrance into service. There is not clear and unmistakable evidence in this case that the veteran's pes planus is congenital or that it otherwise existed prior to service. Therefore, the veteran is entitled to the statutory presumption that his feet were in sound condition when he entered service. His bilateral pes planus was first diagnosed during service, and has been noted in medical records on a number of occasions during and since service. Taking into consideration the medical opinions that the veteran's bilateral pes planus began during service, and the evidence of continuity of his pes planus, the Board finds that the record supports service connection for bilateral pes planus. Diabetes Mellitus The veteran contends that he has diabetes mellitus that began during service. The veteran's service medical records reflect that, on medical examination in February 1993, his fasting blood sugar level was 110 milligrams per deciliter (mg/dl). The examination report contained a notation that the fasting blood sugar was at the upper limits of normal. The laboratory report indicated that the normal range was 76 to 110 mg/dl. In May 1994, treatment notes indicate the veteran's fasting glucose was borderline. Other treatment and laboratory reports indicated that the veteran's glucose level was 105 in April 1987, 131 in April 1994, 98 in August 1994, 102 in March 1995, 109 in May 1995, 109 in June 1995, and 88 in July 1995. After service, laboratory and outpatient treatment reports from the Kansas City, Missouri, VA Medical Center (VAMC) indicated that the veteran's glucose was 117 mg/dl in April 1996, 125 in April 1998, and 129 in December 1998. Notes from April and July 1998 listed an assessment of glucose intolerance. A record from December 1998 listed an assessment of elevated glucose with a question as to whether the veteran had diabetes. In February 1997, a laboratory report indicated that the veteran's A1C was 6.2 %, considered high compared to a reference range of 4.5 to 6.1%. On VA examination in November 1996, the veteran reported that he was diagnosed in 1992 with borderline diabetes. He reported that he followed a diabetic diet with calorie restrictions. He reported that he had intermittent numbness in his hands and feet. The examiner noted normal pedal pulses, and normal hair distribution on the veteran's feet. Laboratory tests revealed glucose of 108 and hemoglobin A1C of 6.2. The examiner's assessment was that the veteran had normal blood sugars, and did not appear to have diabetes. In 1998, VA medical notes indicated that the veteran had elevated glucose with a question of diabetes. Laboratory results during service showed varied glucose levels, some of them borderline or high. The Board finds that the findings of high glucose levels during and after service are sufficient to make the veteran's claim for service connection for diabetes mellitus plausible and well grounded. Additional evidence should be developed, however, to assist with adjudication of the claim. An examination should be performed to clarify whether the veteran currently has diabetes mellitus, and, if so, when that condition began. The remand instructions will follow the decisions on the other issues on appeal. Migraine Headaches The veteran contends that he has migraine headaches that began during service. Service outpatient treatment notes reflect that in September 1975 the veteran reported severe headaches. No diagnosis was made. The veteran was seen in December 1986 for intense recurrent headaches. The examiner's impression was cluster headaches. The veteran reported headaches when he was seen in April 1995, and the examiner's impression was tension-type headaches. Pharmacy notes reflect that from April through June 1995, the veteran received pain medication. Post-service medical records dated in 1996 reflect that the veteran received pain medication. In October 1996, the veteran submitted a headache diary, indicating that in 1995 and 1996 he had suffered headaches with a frequency that averaged several times per month, often more than once in the same day. In April 1997, he submitted an update of the diary, showing that his headaches continued with equal or greater frequency in late 1996 and early 1997. In April 1997, the veteran reported intermittent episodes of chest pain, headaches, and dizziness. On VA examination in November 1996, the veteran reported that he had headaches one to three times per day, with each one lasting between twenty minutes and two hours. He stated that he had had the headaches for more than thirty years. He reported that he took pain medication, but that the medication provided very little improvement in the symptoms. He stated that while a headache was present he could do simple tasks, but that he could not do work that required concentration. He indicated that when possible he tried to lie down and sleep through the headaches when they occurred. The veteran denied any tics, myoclonus complex, or chorea. The examiner's impression was recurrent headaches, not classic of migraine headaches. In July 1997, the veteran's wife wrote that the veteran told her that he had headaches. In a July 1997 hearing at the RO, the veteran reported that he had received treatment during and since service for headaches. He indicated that in 1994 or 1995, he received a prescription medication for the headaches. He reported that the headaches sometimes included pain into his neck. He reported that the pain was sometimes in the sinus area. In a June 1999 letter, the veteran's wife wrote that the veteran had told her that he had headaches. In his June 1999 travel board hearing, the veteran reported he had pain in his face associated with his service-connected sinusitis. He also reported that he had headaches, along with chest pain and dizziness, as symptoms of his service-connected hypertension. The veteran has reported recurrent headaches during and after service. No medical professional has found, however, that the veteran's headaches are migraine headaches. In 1996, a VA physician who examined the veteran specifically stated that the veteran's headaches were not classic of migraine headaches. In the absence of a medical diagnosis that the veteran has migraine headaches, the claim for service connection for migraine headaches does not meet the requirements for a well grounded claim. Therefore, the claim must be denied. Hearing Loss The veteran contends that he has hearing loss that began during service. Service connection has already been established for the veteran's tinnitus. Service connection for hearing loss is regulated at 38 C.F.R. § 3.385, which provides that: For the purposes of applying the laws administered by VA, 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; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). In Hensley v. Brown, 5 Vet.App. 155 (1993), the Court noted that 38 C.F.R. § 3.385, "does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service." 5 Vet.App. at 159. The Court explained that: [W]hen audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. 5 Vet.App. at 160. The veteran's service medical records include records of testing and treatment regarding the veteran's hearing. On audiological evaluation in July 1975, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 10 5 LEFT 25 15 10 10 On audiological evaluation in February 1993, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 15 15 15 LEFT 5 5 15 25 35 On audiological evaluation in March 1995, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 0 10 5 15 LEFT 0 -5 10 15 25 On audiological evaluation in May 1995, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 20 25 30 LEFT 25 25 25 30 40 Outpatient treatment notes from June 1995 reflected that the veteran reported tinnitus, difficulty understanding speech, and episodes of disequilibrium. The examiner found that the veteran had mild high frequency sensorineural hearing loss. The audiological evaluation revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 25 30 LEFT 15 15 15 35 40 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. After service, the veteran sought treatment for tinnitus and hearing problems. On audiological evaluation in March 1996, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 10 15 25 LEFT 15 20 15 20 35 Speech audiometry revealed speech recognition ability of 95 percent in the right ear and of 90 percent in the left ear. VA outpatient treatment notes from 1996 indicated that the veteran had tinnitus and mild hearing loss. On VA medical examination in November 1996, the veteran reported that he had had bilateral tinnitus since 1980, and decreased hearing since 1992 or 1993. He reported that he had difficulty hearing normal conversation, and that the words sometimes sounded blurred. The examiner did not find any abnormality on visual examination of the veteran's ears. Audiological testing was not performed in the November 1996 examination. In October 1998, a VA radiology report noted that the veteran had a history of tinnitus and decreased hearing in the left ear. An MRI of his brain showed no evidence of left sided neuroma or cerebellopontine angle mass lesion. In a July 1997 hearing at the RO, and in his June 1999 travel board hearing, the veteran reported that during service he was exposed to noise from explosions when he served in an artillery unit. He reported that hearing tests during service revealed hearing problems, including tinnitus. He reported that he had continued to have tinnitus and difficulty hearing. In letters submitted in 1997 and 1999, the veteran's wife wrote that the veteran complained about his hearing, and about ringing in his ears. She noted that he stared at people when they spoke, in order to try to understand them despite his problems with his hearing. As there is evidence of hearing impairment during and after service, the claim for service connection for hearing loss is well grounded. The Board also finds that the evidence pertinent to that claim has been developed, such that VA has satisfied its obligation to assist the veteran in the development of that claim. There is some variation in the results of hearing tests in recent years. Nonetheless, a threshold of 40 decibels at 40 Hertz in May and June 1995, during service, and a speech recognition score of 90 percent in March 1996, after service, are adequate to establish that the impairment of hearing in the veteran's left ear meets the regulatory definition of a disability. See 38 C.F.R. § 3.385 (1999). None of the testing has revealed impairment in the veteran's right ear that reaches the level of a disability. Therefore, based on the evidence, service connection is granted for hearing loss in the veteran's left ear, and denied for hearing loss in his right ear. Increased Rating Claims Disability ratings are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (1999). In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2 (1999). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. § 4.10 (1999). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (1999). A CAVC decision established that when a claimant was awarded service connection for a disability, and the claimant subsequently appealed the RO's initial assignment of the rating for those disabilities, the claim is well grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218 (1995). The veteran appealed the ratings initially assigned for his service-connected hypertension, skin disorders, and maxillary sinusitis, and he has continued his appeals after higher ratings were assigned. The rating schedule provides for ratings higher than the ratings currently assigned for each of those disorders. Therefore, the Board finds that all of the veteran's claims for increased ratings are well grounded claims. Hypertension The veteran is seeking a rating higher than the present 20 percent rating for his service-connected hypertension. The Board finds that the facts relevant to the veteran's claim for an increased rating for hypertension have been properly developed, so that VA has satisfied its statutory obligation to assist the veteran in the development of that claim. Under the rating schedule, ratings of 20 percent or higher for hypertension are assigned based on the following criteria: Diastolic pressure predominantly 130 or more ...... 60 Diastolic pressure predominantly 120 or more ...... 40 Diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more ........ 20 38 C.F.R. § 4.104, Diagnostic Code 7101 (1999). The veteran was diagnosed with hypertension during service. After service, medical records from VA and military facilities showed blood pressure readings of 143/81 in August 1995, 113/74 in July 1996, 132/83 in February 1997, and 139/96 in April 1997. In one consultation in June 1997, multiple readings of the veteran's blood pressure showed 138/112, 140/110, 156/120, and 148/118. Records showed readings of 132/89 in July 1997, 157/97 in December 1997, 144/85 in January 1998, 144/87 in March 1998, 143/93 and 136/92 in April 1998, 154/94 in September 1998, 123/66 in December 1998, and 137/89 in April 1999. The records show that the veteran has continued on medications for hypertension during those years. On VA medical examination in November 1996, the veteran's blood pressure ranged from 135/95 to 140/100. The examiner found that the veteran had poorly controlled hypertension. In January 1998, a treating physician noted that the veteran's blood pressure had been under only fair to poor control in recent years. In letters submitted in 1997 and 1999, the veteran's wife noted that the veteran took several medications for his high blood pressure, and that he had headaches and chest pain related to his hypertension. In his July 1997 hearing at the RO and his June 1999 travel board hearing, the veteran reported that he currently took medication for his hypertension. He indicated that physicians had adjusted his medications several times in their efforts to address the hypertension. He reported that he had symptoms of headaches, dizziness, and chest pain related to his hypertension. Based on a review of the medical records, the Board finds that in the years since service the veteran's diastolic pressure has not been predominantly 120 or more. Therefore, a rating of more than 20 percent for his hypertension is not warranted. In reaching this determination, the Board has considered whether staged ratings should be assigned. The Board concludes that the disability has not significantly changed, and that a uniform evaluation is appropriate in this case. Review of the record reveals that the RO did not expressly consider referral of the case to the Chief Benefits Director or the Director, Compensation and Pension Service for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1998). This regulation provides that to accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. The governing criteria for such an award is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. CAVC has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Although the RO did not expressly consider 38 C.F.R. § 3.321(b)(1), the Board has reviewed the record with these mandates in mind, and finds no basis for further action on this question. VAOPGCPREC 6-96 (1996). As the preponderance of the evidence is against a rating in excess of 20 percent for the veteran's hypertension, his claim for an increased rating must be denied. Skin Disorders Service connection has been established for the skin disorders tinea pedis and xerosis. Those disorders, considered together, are currently rated as 10 percent disabling under Diagnostic Code 7806, as comparable to eczema. The veteran is seeking a higher rating. The rating schedule provides the following criteria for evaluating eczema and comparable skin disorders: With ulceration or extensive exfoliation or crusting, and systemic or nervous manifestations, or exceptionally repugnant ................................................. .............. 50 With exudation or itching constant, extensive lesions, or marked disfigurement ............................................. . 30 With exfoliation, exudation or itching, if involving an exposed surface or extensive area ............................. 10 With slight, if any, exfoliation, exudation or itching, if on a nonexposed surface or small area ........................ 0 38 C.F.R. § 4.118, Diagnostic Code 7806 (1999). The veteran was treated during service for skin disorders. In March 1985, a nevus was removed from the left side of his nose. In May 1987, nevi were removed from his right lower back and from the plantar surface of his right foot. In June 1987, he was noted to have flat pigmented lesions scattered over his face. An examiner reported that the lesions appeared benign and not suspicious. In December 1990, he was noted to have lesions on his left jawline, right cheek, chin, and right arm, described as sebaceous hyperplasia and benign nevi. In July 1992, he was noted to have dryness of the scalp, with scabbing. In April 1993, he was seen for a rash on his back and arms, diagnosed as tinea versicolor. In February 1995, the veteran reported chronic irritation of his facial skin, with scaling and itching. He reported intense intermittent itching of his arms and back, and occasionally his legs. The examiner noted macular scaling on the veteran's brow, a maculopapular area on his right cheek, keratosis pilaris on his arms, scattered nevi, seborrheic dermatitis, and xerosis. In April 1995, the veteran was seen for a fungal infection on his right foot. The examiner observed that the veteran's right fourth toenail was thickened and cracked, with onychomycosis. In June 1995, the veteran was seen for flaking, irritation, and itching of the scalp. Pharmacy records dated from February through June 1995 reflected that the veteran received medications for his skin and scalp. After service, the veteran received VA outpatient treatment for skin disorders. The records dated from 1996 to 1998 reflect that various medications for his scalp and skin were prescribed. In March 1996, he reported itching on his abdomen and back. The examiner observed a papular rash, and provided a diagnosis of tinea versicolor. In May 1996, the veteran reported pustules and itching on his scalp. The examiner observed pustules on the scalp, and described the disorder as acne necrotica. On VA examination in November 1996, the veteran reported that during service he had had skin growths removed from his nose, lower back, and foot. He reported that he had a recurrent fungal infection on his feet, and itching of his scalp and back. He reported that he presently had itching on his right foot. The examiner noted a well healed scar on the veteran's lower back. The examiner indicated that the scar did not cause any limitation of function. The examiner did not observe any abnormality on the right foot. In February 1997, the veteran reported daily itching of the head, back, and hands, usually lasting twenty to thirty minutes. The examiner noted one healing papule on the scalp, with no scaling, and clear skin on the back, without papules or pustules. The assessment was seborrheic dermatitis. In April 1997, the veteran reported an ongoing skin disorder, with itching. In May 1997, an examining noted that the veteran had seborrheic dermatitis and folliculitis of the scalp. The veteran reported constant itching of his head, scalp, face, neck, back, and hands. The examiner noted scaling of the scalp and macular and papular areas around the hair follicles. The neck, face, and back were clear. Medications were prescribed. The examiner's impression was seborrheic, infectious, and eczematous dermatitis. In an October 1998 VA dermatology consultation, the veteran reported that his itching had improved. The examiner noted one small erythematous papule in the left nuchal hairline. The remainder of the scalp had several hyperpigmented papules, without suspicious lesions. There was a cystic papule with punctum on the right cheek. The examiner's assessment was folliculitis of the scalp, greatly improved, seborrheic dermatitis of the scalp, compound nevi of the trunk and scalp, and an asymptomatic cyst on the right cheek, reported to have been present for ten years. In a July 1997 hearing at the RO, the veteran reported that his skin disorders caused constant itching of his head, back, and neck. He reported that at times he had been prescribed a tranquilizer to help reduce his scratching of the areas that itched. He reported that getting to sleep was challenging because of the itching of his skin. In letters submitted in 1997 and 1999, the veteran's wife wrote that the veteran scratched his skin all the time, despite using medications on his scalp and skin. She reported that the skin on his neck and scalp became red from scratching, and that there were flaking, dry spots, pus, and scabs on his scalp. In his July 1999 travel board hearing, the veteran reported that his skin itched all the time. He reported that he had dry skin with itching, flaking and scabbing, located primarily on his scalp, but also on his back. He reported that he used prescribed medicated shampoos and ointments. The Board finds that the facts relevant to the veteran's claim for an increased rating for skin disorders have been properly developed, so that VA has satisfied its statutory obligation to assist the veteran in the development of his claim. Medical records have shown continuing lesions, scaling, and reports of itching from the veteran's skin disorders. The evidence does not indicate that the veteran has tender or disfiguring scars, or other disabling manifestations, from the surgical removal of several nevi during service. The veteran and his wife have reported that his itching is constant. The Board views the statements of the veteran and his wife as credible, and finds that the evidence of constant itching is sufficient to support an increase to a 30 percent rating under Diagnostic Code 7806. The evidence does not indicate that the veteran has ulceration, extensive exfoliation or crusting, systemic or nervous manifestations, or exceptionally repugnant manifestations, such as would warrant a 50 percent rating. The Board has considered whether staged ratings should be assigned. The Board concludes that the disability due to the skin disorders has not significantly changed, and that a uniform evaluation is appropriate in this case. Upon review of the record, the Board does not find that there is a basis to refer the claim for consideration of an extraschedular rating for the veteran's skin disorders. Maxillary Sinusitis The veteran is seeking a rating higher than 10 percent for his maxillary sinusitis. He has reported that he receives treatment at the Kansas City, Missouri, VAMC for his sinusitis. Some treatment records from that facility are associated with the claims file, but it does not appear that the file contains the complete records of the veteran's post- service treatment for sinusitis. In addition, under the rating schedule, the frequency of incapacitating and non- incapacitating episodes of sinusitis is an important factor in assigning a rating for sinusitis. The evidence currently associated with the claims file, however, leaves questions as to how frequent such episodes are in the veteran's case. Therefore, the Board finds that additional evidence regarding the veteran's sinusitis should be developed. Specific remand instructions will be provided in the remand portion of this decision. ORDER The claim of entitlement to service connection for a neck disability is well grounded. The claim is granted to this extent only. Entitlement to service connection for low back strain with limitation of motion is granted. The claim of entitlement to service connection for disability of the knees is well grounded. The claim is granted to this extent only. Entitlement to service connection for bilateral pes planus is granted. The claim of entitlement to service connection for diabetes mellitus is well grounded. The claim is granted to this extent only. A well grounded claim for service connection for migraine headaches not having been submitted, the claim is denied. Entitlement to service connection for left ear hearing loss is granted. Entitlement to service connection for right ear hearing loss is denied. Entitlement to a disability rating in excess of 20 percent for hypertension is denied. Entitlement to a disability rating of 30 percent for skin disorders, including tinea pedis and xerosis, is granted, subject to laws and regulations controlling the disbursement of monetary benefits. REMAND Neck The veteran's service and VA medical records include findings of a possible muscular disorder of his neck or possible degenerative joint disease of his cervical spine. X-rays taken on VA examination in November 1996, however, did not show degenerative joint disease of the cervical spine. The veteran should receive a new VA medical examination in order to clarify the nature of the current condition of his neck, and any relationship between any current disorder and service. Knees Some of the medical records have diagnosed the veteran's bilateral knee pain as tendonitis, arthritis, patellofemoral joint syndrome or retropatellar pain syndrome. A post- service VA medical examination indicated that x-rays showed no arthritis of the knees, and that the knees were normal. The veteran should receive a new VA medical examination in order to clarify the diagnosis of any current disorder of the knees, and the relationship between any current disorder and service. Diabetes Mellitus The veteran's medical records have shown varying blood glucose levels, at times borderline or high, with one finding of possible diabetes mellitus. A VA medical examination should be performed to provide a clarified diagnosis as to whether the veteran currently has diabetes mellitus, and an opinion as to whether diabetes mellitus, if present, began during service. Maxillary Sinusitis The veteran has reported that he receives treatment at the Kansas City, Missouri, VAMC for his sinusitis. The RO should obtain complete records of the veteran's treatment at that facility from 1995 through the present. In addition, the veteran should be scheduled for a new VA examination to determine the current manifestations of his sinusitis, with particular attention to the frequency of episodes requiring four to six week courses of antibiotic treatment, and the frequency of episodes with such symptoms as headaches, sinus pain and tenderness, and purulent discharge or crusting. Accordingly, this case is REMANDED for the following: 1. The RO should obtain complete records of outpatient and inpatient treatment of the veteran at the Kansas City, Missouri, VAMC from 1995 through the present. 2. The RO should schedule the veteran for a VA medical examination to clarify the diagnosis of any current disorder affecting his neck and his knees. The examining physician should be provided with the veteran's claims file and a copy of this remand for review prior to the examination. Any necessary tests or studies should be performed, including, but not limited to, x-rays of the veteran's knees. The examiner should provide a diagnosis or diagnoses of any current disorder affecting the veteran's neck and either or both of his knees, including, but not limited to, any arthritis or any muscular disorder. If his neck or either or both of his knees do not currently have any disorder, that should be stated. With regard to each current disorder identified, the examiner should provide an opinion as to whether there is a reasonable basis for concluding that the disorder was present, or had its onset, during the veteran's service. The examiner should explain the reasons and bases for his or her conclusions. 3. The RO should schedule the veteran for a VA medical examination to provide a clarified diagnosis as to whether the veteran currently has diabetes mellitus. The examining physician should be provided with the veteran's claims file and a copy of this remand for review prior to the examination. Any necessary tests or studies should be performed. The examiner should indicate whether the veteran currently has diabetes mellitus. If the examiner finds that the veteran currently has diabetes mellitus, the examiner should provide an opinion as to whether it is as likely as not that the diabetes mellitus was present, or had its onset, during the veteran's service. The examiner should explain the reasons and bases for his or her conclusions. 4. The RO should schedule the veteran for a VA medical examination to determine the current manifestations of his chronic maxillary sinusitis. The examining physician should be provided with the veteran's claims file and a copy of this remand for review prior to the examination. Any necessary tests or studies should be performed. In particular, the examiner should discuss: 1) The number of times per year that the veteran has incapacitating episodes of sinusitis that require a four to six week course of antibiotic treatment. 2) The number of times per year that the veteran has non-incapacitating episodes characterized by headaches, sinus pain, and purulent discharge or crusting. 3) If the symptoms of the veteran's sinusitis, such as headaches, sinus pain, and purulent discharge or crusting, are present nearly constantly, rather than episodically, the examiner should affirmatively indicate that finding. The examiner should explain the reasons and bases for his or her conclusions. 5. The RO should inform the veteran that he may submit additional evidence and argument on the matters the Board has remanded to the RO. See Kutscherousky v. West, 12 Vet. App. 369 (1999). After the completion of the foregoing development, the RO should review the case. If the decision on any issue remains adverse to the veteran, he and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate consideration, if otherwise in order. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals 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 ROs to provide expeditious handling of all cases that have been remanded by the Board and CAVC. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. JEFF MARTIN Member, Board of Veterans' Appeals