Citation Nr: 1327313 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 99-15 298 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a rating in excess of 40 percent for chondromalacia of the right patella. 2. Entitlement to a rating in excess of 20 percent for prostatitis. 3. Entitlement to a compensable rating for a history of otitis media and otitis externa. 4. Entitlement to a total disability rating due to unemployability caused by service-connected disabilities. 5. Entitlement to an effective date earlier than April 16, 2001 for the assignment of a 20 percent evaluation for prostatitis. 6. Entitlement to an effective date earlier than May 14, 1998 for the assignment of a 30 percent evaluation for allergic rhinitis with sinusitis. REPRESENTATION Appellant represented by: Allen T. Fenley, Attorney ATTORNEY FOR THE BOARD K. Kordich, Senior Counsel INTRODUCTION The Veteran served on active duty from July 1976 to June 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal of a February 1999 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In that decision, the RO granted a 40 percent evaluation for service-connected chondromalacia patella of the right knee, effective from May 14, 1998, the date of receipt of the Veteran's claim for increase. In that same decision, the RO denied the Veteran's claims for a rating in excess of 10 percent for prostatitis; a compensable rating for a history of otitis media and otitis externa; and a total disability rating due to unemployability caused by service-connected disabilities (TDIU). The Veteran disagreed with those decisions and appealed to the Board. In December 2000, the Board remanded the case to the RO for additional development. In a May 2002 rating decision, the RO granted a 20 percent evaluation for service-connected prostatitis, effective from April 16, 2001, the date of a VA examination for compensation purposes. The RO also granted a 10 percent evaluation for service-connected allergic rhinitis with sinusitis, effective from May 14, 1998, the date of receipt of the Veteran's claim for increase. However, these ratings did not represent a full grant of benefits, and therefore those claims remained on appeal. The Veteran also filed timely appeals as to the effective dates of these increases, and those claims were merged with the current appeal. In August 2002, the Board raised the Veteran's rating to 30 percent for his service-connected allergic rhinitis and sinusitis, and indicated that it was undertaking additional development on the issue of entitlement to a TDIU. However, the Board denied a rating in excess of 40 percent for the chondromalacia of the right patella; in excess of 20 percent for prostatitis; and denied a compensable rating for a history of otitis media and otitis externa. Except for the increased rating for allergic rhinitis and sinusitis, the Veteran disagreed with those decisions and appealed to the United States Court of Appeals for Veterans Claims (Court). In a September 2002 rating action, the RO continued May 14, 1998 as the effective date of the 30 percent rating for allergic rhinitis and sinusitis. In February 2003, pursuant to a joint motion by the Veteran and VA, the Court vacated the Board's August 2002 decision as it pertained to the denials of increased ratings for chondromalacia of the right patella, prostatitis and the history of otitis media and otitis externa. The Court then remanded the case for readjudication consistent with the motion. The Court noted in its Order that the appeal as to the remaining issue of an increased rating for service-connected allergic rhinitis with sinusitis was dismissed. In September 2003, the Board remanded the issues of increased evaluations for the chondromalacia of the right patella, prostatitis, and history of otitis media/otitis externa to the RO for additional development. The Board also included the issue of entitlement to a TDIU. In June 2004, following the requested development, the RO confirmed and continued the 40 percent rating for the chondromalacia of the right patella; the 20 percent rating for prostatitis; and the noncompensable rating for the history of otitis media and otitis externa. The RO also confirmed and continued the denial of a TDIU. Thereafter, the case was returned to the Board. In a September 2004 decision, the Board denied increased ratings for the chondromalacia of the right patella, the prostatitis, and for the history of otitis media and otitis externa. The Board also denied a TDIU. Thereafter, the Veteran appealed the Board's decision to the Court. In its September 2004 decision, the Board also remanded the claims for earlier effective dates for the assigned ratings for allergic rhinitis and sinusitis and for prostatitis for further development. The record reflects that the RO has since that time not complied with the Board's instructions. Those issues therefore will be further addressed in the remand portion of the action. In May 2006, the Court vacated the Board's September 2004 decision with respect to the denials of increased ratings for chondromalacia of the right patella, prostatitis, and history of otitis media and otitis externa. The Court also vacated the Board's denial of entitlement to a TDIU. The Court remanded those matters to the Board for readjudication consistent with the Court's order. In March 2007 and March 2010, the Board remanded the above to the RO for additional development. Thereafter, the case was returned to the Board. The case has now been returned to the Board for further appellate consideration. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issue of entitlement to a total rating due to unemployability caused by service-connected disabilities and the earlier effective date issues are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected chondromalacia patella of the right knee is manifested by degenerative joint disease and disability equivalent to nonunion of the tibia and fibula with loose motion requiring a brace, but not by ankylosis or extension limited to 20 degrees or more, or flexion limited to 15 degrees. 2. The Veteran's service-connected prostatitis is presently characterized by no more than a daytime voiding interval between 1 and 2 hours, or awakening to void 3 to 4 times per night. 3. The Veteran's service-connected otitis media/otitis externa is not manifested by active suppuration or aural polyps; but is manifested by otitis externa with itching requiring frequent and prolonged treatment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 40 percent for chondromalacia patella of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.71a and Part 4, Diagnostic Code 5262 (2012). 2. The criteria for an evaluation in excess of 20 percent for prostatitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.7, 4.21, 4.115, Diagnostic Code 7527 (2012). 3. The criteria for a 10 percent evaluation for a history of otitis media and otitis externa have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.87, Diagnostic Codes 6200, 6210 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) include enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims(s); (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirement applies to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Dingess/Hartman also held that in rating cases, a claimant must be informed of the rating formula for all possible schedular ratings for an applicable rating code, and that VA must provide information regarding the effective date that may be assigned. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Sec'y of Veterans Aff., 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. In its May 2006 decision, the Court referenced the three elements of the VCAA in the duty of VA to notify the Veteran. The Court noted that such notice had to be sent prior to the adjudication of the Veteran's claim and was not satisfied by various post-decisional documents from which the Veteran could infer what was lacking in his presentation. In reviewing the Board's September 2004 decision, the Court noted the Board's determination that notice provided to the Veteran had been adequate. However, the Court found that in reaching its decision, the Board had impermissibly relied, at least in part, on documents that had not been issued prior to the initial adjudication of the Veteran's claims by the RO. Consequently, the Court vacated the Board's September 2004 decision and remanded the matter to the Board for compliance with the Court's order. Thereafter, the RO provided notice to the Veteran in September 2006 and April 2007 letters explaining what information and evidence was needed to substantiate the claims for increased ratings for his service connected chondromalcia of the right patella, prostatitis, otitis media and otitis externa, and entitlement to a TDIU. The letters also included what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The April 2007 letter also provided notice with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The case was thereafter readjudicated in a November 2009 Supplemental Statement of the Case (SSOC). The Board finds that the Veteran has received the notice to which he is entitled. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters on appeal. Service treatment records (STRs) and all available post-service medical evidence identified by the Veteran has been obtained. As a result of a March 2010 Board remand, additional outstanding medical records as well as employer records from Norfolk Ship Repair and Dry Dock Company and the Planters Peanut Company were identified for the RO to obtain. In addition, the RO was asked to provide the Veteran with both old and new rating criteria for evaluating otitis media and otitis externa in a SSOC. In February 2012, the RO provided the Veteran with further VCAA notification as well as asking the Veteran to provide information on medical providers so that further medical information could be obtained. In a letter dated in May 2012 as well as subsequent SSOCs the RO provided the rating criteria for otitis media and otitis externa. In February 2012, the RO sent letters to Norfolk Ship Repair and Dry Dock Company and the Planters Peanut Company for information concerning the Veteran's employment. In April 2013, Kraft Foods, the parent company of Planters Peanuts, responded that they did not have any records pertaining to the Veteran. A second request for records from Norfolk Ship Repair was made in February 2013. The RO also informed the Veteran, via letter than month, that a second request was being made because no response had been received as a result of the initial request in February 2012. The Veteran was advised that he could obtain the records himself and that VA may decide his claim after it has completed its current attempts to obtain the evidence. This letter satisfies 38 C.F.R. § 3.159(e) which pertains to VA's duty to notify a claimant of its inability to obtain records. Pertinent medical evidence associated with the claims file consists of private medical treatment records and examinations from various private physicians as well as VA treatment records and examinations. In an April 2012 SSOC, the RO notified the Veteran that there was no response from Norfolk Naval Shipyard and Planters Peanuts concerning the availability of the Veteran's employment records. The Board notes that in the prior VCAA letters, the Veteran was made aware that it was ultimately his responsibility to ensure pertinent non-Federal records were obtained. The Veteran has been afforded appropriate medical examinations in regard to the claims decided herein. The examination reports dated in October 1998 (with a January 1999 addendum), April 2001, June 2004, October 2009 (prostatitis examination), and April 2012 are adequate for adjudicative purposes. The examiners reviewed the Veteran's records, subjective complaints, and examination findings. Thereafter, the examiners rendered medical findings and opinions with sufficient reasons and bases. In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A, or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claims below, the Board has reviewed all of the evidence in the Veteran's claims file including those found in Virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the Veteran's claims folder shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background On VA fee-basis ear, nose and throat examination in October 1998, the Veteran gave a history of bilateral otalgia of two weeks' duration. Physical examination revealed intact tympanic membranes bilaterally, with no evidence of erythema or drainage. At the time of examination, no pertinent diagnosis was noted. On VA fee-basis orthopedic/genitourinary examination in October 1998, the Veteran complained of, among other things, a prostate condition and a right knee condition. Noted at the time of examination was a history of ear infections, for which the Veteran was receiving treatment at the local VA medical center. Also noted was a history of prostatitis dating back to 1977. According to the Veteran, he continued to have "flare ups" of prostate infections once or twice a year, for which he took medication. Reportedly, the Veteran had seen a urologist just a few days earlier. Currently, the veteran was experiencing symptoms of difficult urination, with difficulty initiating a urine stream, a slow and/or split stream, and slight dysuria. When questioned regarding his right knee, the Veteran stated that he had injured it in 1977 onboard ship. As a result of continuing problems with pain, grinding, and popping in the right knee, the Veteran eventually underwent arthroscopic surgery in 1990. Reportedly, at that time, he was informed that there was cartilage damage. Currently, the Veteran was receiving prescribed pain medication, a knee brace, and physical therapy. When questioned, the Veteran complained of stiffness and occasional instability in his right knee. Reportedly, he experienced pain in his knee every other day, which might last the whole day, and which was precipitated by increased walking or use. On physical examination, the Veteran's tympanic membranes displayed chronic changes bilaterally. The right ear canal was, however, normal. Genitourinary examination was essentially unremarkable. Noted at the time of examination was that the Veteran did require a right knee brace. The Veteran's right knee showed no swelling, and the knee was nontender. There was slight crepitus on range of motion, with active flexion of 140 degrees, and active extension of 5 degrees, consistent with a lack of 5 degrees of full extension. The Drawer test was within normal limits, as was McMurray's test. Neurologic evaluation of the lower extremities was within normal limits. Radiographic studies of the Veteran's right knee were consistent with mild degenerative changes, in particular, in the femoropatellar joint. The pertinent diagnoses were chronic prostatitis; and postoperative right knee derangement, with chondromalacia patella and mild degenerative joint disease. In a January 1999 addendum to the aforementioned VA ear, nose and throat examination, it was noted that, on physical examination, the Veteran's external auditory canals were clear, with no sign of infection, purulent drainage, edema, or tenderness to palpation. Nor was there any sign of otitis externa or otitis media. Based on physical examination, the examiner was of the opinion that there was no reason why the Veteran should not be able to work. Received in January 2001 were VA outpatient treatment records covering the period from February 1995 to December 2000. Those records show treatment for prostatitis, and various right knee problems. Also received in January 2001 were private medical records from S.B.C., M.D. covering the period from July 1995 to December 2000. Those records show treatment for various right knee problems. An examination dated in December 2000 showed that the Veteran had good range of motion of both knees with pain. The examination did not show crepitus or laxity. Received in February 2001 were private outpatient treatment records from R.G., M.D. covering the period from December 1997 to July 1999. Those records show treatment for prostatitis. In correspondence of July 1998, the Veteran's private physician stated that he had seen the Veteran in early July for evaluation of his voiding complaints of split stream, urgency, nocturia, and mild suprapubic tenderness. Reportedly, the Veteran had experienced these same symptoms with prostatitis in the past. The Veteran denied other voiding complaints, and was otherwise in good health. On examination, the Veteran's prostate was slightly tender. His genitalia were unremarkable, and urine analysis was negative. Following evaluation, the Veteran was begun on medication for prostatitis, with follow up to occur in 6 to 8 weeks. On VA fee-basis orthopedic/genitourinary examination in April 2001, the Veteran stated that his prostatitis had not gotten any better. Reportedly, the Veteran continued to experience slow urination, with the need to strain in order to pass urine. Also noted was that the Veteran's problem resulted in a dark-colored stain in his undergarments, resulting from dribbling after urination. The Veteran further stated that his chondromalacia patella had gotten worse. According to the Veteran, he continued to experience soreness and aching in his muscles, as well as pain in his knee with weather changes. However, the Veteran's knee cap did not "pop out." Regarding his history of prostatitis, the Veteran stated that he had suffered from prostate disease, consisting of enlargement of his prostate and prostatitis, since 1976. Currently, the Veteran was being treated with medication. However, he had not yet completed that treatment. According to the Veteran, he typically urinated three times during the day and three times at night. Occasionally, the Veteran experienced pain with urination, as well as a weak stream. Reportedly, the Veteran had some problems with incontinence, though he denied wearing pads. Regarding chondromalacia patella of the right knee, the Veteran complained of pain in conjunction with popping, grinding, soreness, a loose kneecap, and weak muscles. Reportedly, "flare ups" occurred on an "off and on" basis, and were uncomfortable to distressing. While the Veteran had been prescribed medication, it did not totally alleviate his pain. Noted at the time of examination was that the Veteran was able to walk short distances. Certain other activities he was unable to do as a result of physical limitations from his right knee. Physical examination was grossly unremarkable, with no sign of abnormal weight bearing. There was a brace on the Veteran's right knee, which he admitted he had to wear due to a problem with his kneecap popping out. The Veteran's posture was slightly abnormal, and he displayed a very mild abnormal gait, favoring his right knee. At the time of examination, there was no limitation of standing and walking. Examination of the Veteran's right knee demonstrated abnormal movement of 110 degrees accompanied by pain, with extension to 0 degrees. The Drawer and McMurray's test were within normal limits, bilaterally, and there was no evidence of any laxity. However, the Veteran's right knee did give him some pain. On rectal examination, the Veteran's prostate gland was slightly enlarged, but smooth in consistency, with no nodules. Radiographic studies of the Veteran's right knee were consistent with patella alta in association with chondromalacia and mild degenerative changes within the various compartments of the knee. The pertinent diagnoses were prostatitis, with subjective complaints of dribbling, infection, and staining of undergarments; and patella alta, with chondromalacia and mild degenerative changes of the right knee. On VA fee-basis ear, nose and throat examination, likewise conducted in April 2001, it was noted that a discussion with the Veteran revealed that he had experienced some sporadic ear problems, which might have been otitis externa. More likely, however, was that the Veteran's symptoms were the result of an underlying chronic allergic rhinitis, which had an adverse effect on his nasal congestion and eustachian tube dysfunction. On physical examination, both of the Veteran's eardrums were normal in appearance and mobility, and both external auditory canals were clear. There was no infection present, either along the external canal, or in the middle ear space. In the opinion of the examiner, the Veteran had a resolved condition of otitis media and otitis externa. He concluded that various findings referable to the Veteran's ears would not prevent him from engaging in substantially gainful employment. Private medical records from S.L., M.D. received in January 2002 covering the period from August 1987 to August 1993 showed treatment during that time for various back and right knee problems. Received in May 2002 was a copy of an examination of the Veteran by a private physician. At the time of that examination, the Veteran complained of dysuria, frequency and impotence. Reportedly, the Veteran had initially been treated with medication, which provided some relief. However, his symptoms were now becoming worse. Physical examination revealed a healthy appearing male in no acute distress. Rectal examination revealed a benign prostate gland which was only minimally tender, and not boggy. At the time of examination, urine analysis was clear. The clinical impression was chronic nonbacterial prostatitis. Also received in May 2002 was a copy of another examination of the Veteran by S.B.C., M.D. dated in October 2001. The Veteran complained of increasing pain in his right knee. Reportedly, the Veteran had been told that he was suffering from patellofemoral arthritis. According to the Veteran, he had been put in a Q-brace, and told that he might need surgery to "straighten out his patellar malalignment." On physical examination, there was severe crepitus with range of motion of the right knee, though with no effusion, warmth, or pain over the medial and lateral tibial plateau or femoral condyles. The clinical assessment was osteoarthritis of the right knee "especially the patellofemoral." Received in February 2004 were private medical records from R.G., M.D. covering the period from May 2001 to October 2003. Those records showed treatment for, among other things, prostatitis. During the course of treatment in early July 2003, it was noted that the Veteran has experienced no recent problems with prostatitis. Reportedly, he was voiding well. Physical examination revealed a nontender abdomen, with no palpable masses. The Veteran's testes and phallus were within normal limits, and his prostate was 1+/4 in size, with no palpable nodules, or evidence of tenderness. Urine analysis was negative. The clinical impression was history of prostatitis; and benign prostatic hypertrophy. During the course of private treatment in early October 2003, the Veteran stated that, the previous week, he had experienced some worsening symptoms of prostatitis, which since that time had somewhat improved. Currently, the Veteran continued to experience mild discomfort. However, his voiding pattern was good on medication. On physical examination, the Veteran's abdomen was benign. The prostate gland was mildly tender and 1+/4 in size, with no palpable nodules. Urine analysis was, once again, negative. The clinical impression was mild exacerbation of prostatitis and benign prostatic hypertrophy. Received in March 2004 were private medical records from P.M., M.D, of Greenbrier ENT covering the period from August 2000 to February 2004, showing treatment during that time for various ear problems. During the course of private outpatient treatment in early September 2001, it was noted that the Veteran had been experiencing pain and itching in his right ear. Private medical records covering the period from March to May 2002 showed continued problems with itching of the ears. In late March 2003, there was noted the presence of dried blood in the Veteran's right ear. Apparently, the Veteran had noticed this on two occasions. Noted at the time of evaluation was that the Veteran had experienced an ear infection two months earlier. On physical examination, the Veteran's right ear was described as "healed." In June 2004, a VA ear, nose and throat examination was accomplished. At the time of examination, it was noted that the Veteran's claims folder was available, and had been reviewed. According to the Veteran, he had experienced the onset of ear infections (external otitis) around 1997. Reportedly, this was somewhat worse in the right ear, though occasionally, the left ear was also involved. The Veteran was treated with drops, which resulted in a clearing of his infection. Reportedly, the Veteran's last episode was in February 2004, at which time he was given drops, and the symptoms cleared. The Veteran's chief complaint consisted of frequent itching and aching in his right ear. On physical examination, the Veteran's external ears and ear canals were within normal limits. Both tympanic membranes were intact and mobile, and there was no evidence of any middle ear fluid or infection. At the time of examination, both mastoids were within normal limits. The pertinent diagnosis was no external otitis or otitis media, though the Veteran did have recurrent itching of the external auditory canal. On VA genitourinary examination, likewise conducted in early June 2004, it was noted that a review of the Veteran's medical records showed the onset of prostatitis in 1976. Reportedly, the Veteran received treatment with antibiotics, and his symptoms cleared. The Veteran's last episode of prostatitis was reportedly in March of 2004, at which time he received treatment with medication, and the symptoms once again cleared. According to the Veteran, the previous year, he had experienced approximately three episodes of prostatitis. The Veteran complained of difficulty voiding, for which he took medication. Reportedly, he had been on this medication for three years. According to the Veteran, his stream was slow, though he never had to be catheterized due to an inability to void. Nor had the Veteran experienced any urinary incontinence. On physical examination, rectal examination revealed a somewhat enlarged prostate, but with no masses. The pertinent diagnosis was recurrent prostatitis. On VA orthopedic examination in June 2004, it was noted that a review of the Veteran's medical records showed that, in 1990, he had undergone arthroscopy of his right knee. Following this operation, the Veteran's right knee was better for a period of time, though it currently hurt 3 to 4 times per week, with a pain level of 4-5. According to the Veteran, approximately once per year, he received an injection of cortisone into his right knee. Additionally noted was that the right knee occasionally locked, especially when the Veteran was getting out of bed. However, upon arising from bed, the Veteran's right knee typically unlocked, and he was able to walk. When questioned, the Veteran stated that he had never fallen. Reportedly, the Veteran's right knee caused him pain approximately 3 to 4 times per week, with the pain lasting approximately two hours. Also noted was that the Veteran wore a right knee brace "all the time." However, he had never utilized a walker or special shoes. On physical examination, the Veteran's right knee showed no evidence of any redness or swelling, though the right knee was slightly tender above the patella. The Veteran was able to flex his right knee from 0 to 120 degrees, and though there was some tightness at 120 degrees, there was no pain. According to the examiner, the Veteran's right knee could not be passively flexed beyond 120 degrees. Repeated flexion of the right knee to 120 degrees caused no pain or weakness. Nor was there any evidence of induced fatigue or lack of endurance. Extension of the right knee was to 0 degrees, though with pain in and around the patella, superiorly, at 0 degrees. However, the Veteran was able to lift his leg straight up without any difficulty. Repeated extension of the right knee resulted in an increase in pain, but no weakness, fatigue, or lack of endurance. Noted at the time of examination was that there was no evidence of any knee effusion or Baker's cyst in either knee. The medial and collateral ligaments were stable for both knees, and both the anterior and posterior cruciate ligaments were intact. At the time of examination, there was no evidence of a cartilage tear in either knee. Nor was there any evidence of muscle weakness or atrophy. The Veteran's posture and gait were good and sensation over both lower legs was normal. The pertinent diagnosis was chondromalacia patella of the right knee. In an addendum to the aforementioned examination, the examiner stated that the Veteran did not suffer from any incapacitating medical problems which would prevent him from finding and retaining employment. An October 2006 treatment report from K.B., M.D. showed audible patellofemoral crepitation throughout range of motion. The Veteran had no medial or lateral joint line pain. There was no effusion. Range of motion was 0 to 135 degrees with pain. X-rays showed slight lateral facet compression. MRI showed a large area of full thickness cartilage loss in the patellar and lateral facets of the femoral trochlea, basically lateral patellofemoral arthritis with mild subluxation. A treatment report from December 2007 noted that the Veteran reported pain in his right knee was worse. The examination showed severe patellocrepitation and pain. Range of motion was 0 to 130 degrees. The Veteran was diagnosed with advanced patellofemoral arthritis. In January 2008, the Veteran underwent a right knee arthroscopy for degenerative arthritis. Treatment records from J.T., M.D. dated from April 2008 to October 2009 contain ears, nose, and throat (ENT) treatment. An audiogram showed hearing essentially equal in both ears with a slight dip in the right ear in the high frequency area. The speech reception thresholds (SRTs) and discriminations were both well within the normal range and he had normal responses to tympanometry tests. An October 2009 treatment record notes that the Veteran was seen for his ears. It was noted that he was last seen in August with pain in the right ear. It was felt at that time to be herpes zoster oticus and he responded very quickly to Acyclovir. He came in for a follow-up visit and reported no interim problems except for a respiratory infection. The operative report from Chesapeake General Hospital shows that the Veteran underwent arthroscopic right knee surgery and debridement of the patellofemoral compartment in January 2008. A treatment report from B.B., M.D. dated in August 2008 noted consultation for possible sinus infection. The Veteran had upper respiratory symptoms, throat pain, allergic rhinitis, and itching of the right ear canal. For the itching of the right ear, the Veteran was prescribed drops to use as needed. At an October 2009 VA audiometric examination, the Veteran complained of losing his hearing 2 to 3 times a year with a worsening of the ringing. He also complained of ear infections which occurred 3 to 4 times a year. An audiogram was conducted and the Veteran had normal auditory acuity bilaterally with good word recognition ability at normal. At an October 2009 VA orthopedic examination of his right patella, the Veteran stated he had surgery in 2008 in which he had tissue cut and the affected area was shaved with realignment. He was being followed by a rheumatologist with 6 month checkups. He had a Cortisone shot the month prior and was told the next recommendation would be total knee replacement. The Veteran reported giving way, instability, pain, stiffness, weakness, and decreased speed of joint motion. The Veteran experienced locking episodes one to three times a month. He was able to stand up to one hour and walk up to three miles. The examination showed his gait was normal. There was crepitus, tenderness, pain at rest, and guarding of movement. There was no instability and range of motion for flexion was 120 degrees and extension was 0 degrees. Range of motion for flexion was additionally limited to 100 degrees upon repeated activity due to pain. X-ray showed minimal degenerative changes. The diagnosis was chondromalacia/degenerative joint disease of the right knee. At an October 2009 VA genitourinary examination, the Veteran reported prostatitis flare-ups every 4 to 6 months. Medical history report noted urgency, difficulty starting stream, dysuria, straining to urinate, and urine retention. Daytime voiding occurred every two to three hours and nighttime voiding occurred four times per night. The examination showed that the Veteran's prostate was enlarged. The diagnosis was chronic prostatitis. Private medical records from B.S., M.D. dated April 2010 to June 2010 show treatment for Meniere's disease to include an intratympanic profusion of Decadron therapy to his left ear for treatment of his symptomatic cochlear Meniere's disease. A March 2010 Board decision remanded in part for outstanding private treatment records and to schedule a new examination for otitis media and otitis externa finding that the October 2009 VA examination was inadequate for rating purposes. Additional medical records received in 2012 included private medical records from Urology of Virginia dated from September 2006 to October 2007 which show complaints of hesitancy and urinary dribbling after voiding. At an April 2012 VA examination, the Veteran reported a history of otitis media and Meniere's disease. Results of audiometric tests showed normal auditory acuity with excellent word recognition ability at normal intensity levels. Tympanograms showed normal middle ear pressure and compliance. The Veteran reported being typically treated for infections three to four times a year. He reported decreased hearing and vertigo when his ears were infected. The examination showed no benign neoplasm of the ear causing any impairment of function. At the time of the examination, the Veteran had no findings, signs, or symptoms attributable to chronic ear infection, inflammation, or cholesteatoma. Ear canal, tympanic membrane, and external ear were noted as normal. There was no dry and scaling or serous discharge of the external canal. There was no itching of the external ear canal, no active suppuration, no aural polyps, and no bone loss of the skull. Laws and Regulations The Veteran in this case seeks increased evaluations for service-connected chondromalacia patella of the right knee, prostatitis, and otitis media/otitis externa. In that regard, disability evaluations are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). In evaluating the severity of a particular disability, it is essential to consider its history. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1, 4.2 (2012). However, 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. Though a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give medical history precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Evaluation in Excess of 40 Percent for Chondromalacia Patella of the Right Knee The Veteran's service-connected chondromalacia of the right patella has been evaluated as 40 percent disabling under Diagnostic Code 5262, which contemplates malunion of the tibia and fibula, with loose motion requiring a brace. The 40 percent disability rating is the maximum rating which can be assigned under this diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2012). Knee disabilities, including degenerative arthritis, are also rated based on limitation of motion and instability. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Diagnostic Codes 5260 and 5261 provide the criteria for rating limitation of motion of the knee and leg. Normal range of motion for the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II (2012). Under Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to at least 45 degrees. A 20 percent rating is assigned for flexion of the leg limited to 30 degrees. A 30 percent rating is assigned for flexion of the leg limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Under Diagnostic Code 5261, a 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension of the leg limited to 15 degrees. A 30 percent rating is assigned for extension of the leg limited to 20 degrees. A 40 percent rating is assigned for extension of the leg limited to 30 degrees. A 50 percent rating is assigned for extension of the leg limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Additionally, the evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same joint. See VAOPGCPREC 9-04. Under Diagnostic Code 5257, a 10 percent evaluation is assigned for slight recurrent subluxation or lateral instability of the knee. A 20 percent evaluation is assigned for moderate recurrent subluxation or lateral instability of the knee, and a 30 percent evaluation is assigned for severe recurrent subluxation or lateral instability of the knee. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The General Counsel for VA, in VAOPGCPREC 23-97, held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. General Counsel stated that when a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion which at least meets the criteria for a 0 percent rating under Diagnostic Code 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. General Counsel subsequently held in VAOPGCPREC 9-98 that a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Where additional disability is shown, a veteran rated under Diagnostic Code 5257 can also be compensated under Diagnostic Code 5003 and vice versa. Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2012); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes is to be avoided when rating a veteran's service-connected disabilities. See 38 C.F.R. § 4.14 (2012). As already noted, the Veteran is in receipt of the maximum evaluation assignable under Diagnostic Code 5262. The Board notes that this Diagnostic Code provides for lower ratings where there is "marked knee...disability". Multiple ratings for the Veteran's service-connected right knee disability are not for consideration, inasmuch as the weight of the evidence is to the effect that the Veteran does not, in fact, suffer from both arthritis and instability of his right knee. See VAOPGCPREC 23-97; VAOPGCPREC 9-98. The Board acknowledges the reference at the April 2001 examination to evidence of subluxation, but notes that clinical examinations of the knee have not established the presence of recurrent subluxation or instability. In any event, the Board points out that there is no suggestion in the record that any instability or subluxation is more than mild in nature. Moreover, the Veteran's flexion and extension have consistently been shown to be noncompensable, even with consideration of functional loss due to pain. At most the Veteran experiences flexion limited to no more than 100 degrees and extension limited by no more than 5 degrees. Thus, separately rating any instability and loss of motion pursuant to VAOPGCPREC 23-97 would not result in a higher rating than the 40 percent currently assigned. Moreover, since Diagnostic Code 5262 specifically contemplates knee disability of any type, it would violate the rule against pyramiding to assign separate ratings in addition to that under Diagnostic Code 5262. The 40 percent evaluation currently in effect contemplates the presence of impairment of the tibia and fibula, which is to say nonunion, with loose motion, requiring a knee brace. In order to warrant an increased evaluation, there would need to be demonstrated a limitation of extension to 45 degrees, or ankylosis of the Veteran's right knee. 38 C.F.R. § 4.71a and Part 4, Codes 5256, 5261, 5262 (2012). This is because Diagnostic Code 5262 specifically contemplates any knee disability. Thus, the evidence must show that the Veteran is entitled to higher than a 40 percent rating under another Diagnostic Code. Based on the aforementioned findings, it is clear that the Veteran does not, in fact, exhibit a limitation of extension to 45 degrees or limitation of flexion that would warrant even a compensable evaluation. The examinations and evaluations show that, even with consideration of pain, the Veteran's extension is limited by no more than 5 degrees, and his flexion is at least to 100 degrees. Consequently, separately evaluating the flexion and extension of the knee would not result in a rating in excess of 40 percent. Nor is there any evidence of ankylosis of the Veteran's right knee. Based on the evidence of record, and, in particular, the continued use of a brace for the Veteran's right knee, the 40 percent evaluation currently in effect is appropriate, and an increased rating is not warranted. The Board notes that Diagnostic Code 5256 is not applicable, as the evidence does not indicate the Veteran has ankylosis of the right knee. A rating under Diagnostic Codes 5257, 5258, 5259, or 5263 is not appropriate, as the Veteran does not exhibit symptoms of genu recurvatum or removal of semilunar, symptomatic cartilage. Furthermore, the Board finds that the symptoms described by Diagnostic Codes 5257, 5258 and 5259, are already addressed by the Veteran's currently assigned rating under Diagnostic Code 5262 (instability, locking and subluxation, pain and effusion). As such, a rating under these codes is not appropriate, as it would result in pyramiding. There is also no indication that the Veteran experiences any additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45 (2012); see also DeLuca, supra. Significantly, the Board considered the point at which the Veteran first experienced pain when determining his level of knee disability. Further, while the VA examiners noted the Veteran's complaints of additional pain with repetitive motion, there is no evidence of additional limitation of motion or functional impairment, other than that already recognized by the Veteran's currently assigned evaluation. As such, an increased rating under DeLuca is not warranted. Further, the Board notes that there is no indication in the medical evidence of record that the Veteran's right knee symptomatology warranted other than the currently assigned 40 percent disability rating throughout the appeal period. As such, assignment of staged ratings is not warranted. See Hart, supra. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased rating for chondromalacia of the right patella, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Evaluation in Excess of 20 Percent for Prostatitis The Board observes that, pursuant to applicable law and regulation, the Veteran's service-connected prostatitis is rated on the basis of either voiding dysfunction or urinary tract infection, whichever is predominant. In that regard, a 10 percent evaluation is warranted for marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream). A 10 percent rating is also warranted for urinary tract infection requiring long term drug therapy, 1 to 2 hospitalizations per year, and/or requiring intermittent intensive management. In that regard, a 20 percent evaluation is warranted where there is a daytime voiding interval between 1 and 2 hours, or awakening to void 3 to 4 times per night. A 20 percent evaluation is also indicated where there is a need for absorbent materials which must be changed less than two times per day. A 30 percent evaluation is warranted for urinary retention requiring intermittent or continuous catheterization. A 30 percent rating is also warranted for urinary tract infection that is recurrent and symptomatic that requires drainage, frequent hospitalizations, and/or requiring continuous intensive management. A 40 percent evaluation, on the basis of urinary frequency, would require demonstrated evidence of a daytime voiding interval less than one hour, or awakening to void 5 or more times per night. A 40 percent evaluation on the basis of voiding dysfunction would, likewise, be indicated where there was a need for absorbent materials which required changing 2 to 4 times per day. 38 C.F.R. § 4.115 and Part 4, Code 7527 (2012). Regarding the Veteran's claim for increased benefits for prostatitis, the Board notes that, on VA examination in April 2001, the Veteran indicated that he was currently receiving treatment in the form of medication, but still found it necessary to urinate three times during the day, and approximately three times at night. On a VA genitourinary examination in June 2004, the Veteran complained of difficulty voiding, for which he took medication. While the Veteran's urinary stream was somewhat slow, he denied any history of catheterization due to an inability to void. Nor was there any evidence of urinary incontinence. Private treatment reports document complaints of urinary hesitancy and dribbling after voiding. At an October 2009 VA genitourinary examination, the Veteran reported prostatitis flare-ups every 4 to 6 months, with complaints of urgency, difficulty starting stream, dysuria, straining to urinate, and urine retention. Daytime voiding occurred every two to three hours and nighttime voiding occurred four times per night. Based on the aforementioned, it is clear that the 20 percent evaluation currently in effect for service-connected prostatitis is appropriate, and that an increased rating is not warranted. The predominant disability picture for the Veteran is clearly that involving voiding intervals. The Veteran has consistently reported voiding no more frequently than every 2 hours during the day, and no more than 4 times at night. This is the frequency precisely contemplated by the 20 percent evaluation for the disorder. Although the Veteran reports dribbling, he has never reported requiring the use of absorbent materials, and has denied actual incontinence. Thus, the evidence does not show evidence of incontinence requiring the use of absorbent materials, or the need to urinate approximately every hour or less or at least 5 times at night. Nor does the relative infrequency of his bouts of prostatitis even remotely approximate requiring frequent drainage or hospitalization or continuous intensive management. Under such circumstances, the Veteran's claim for an increased evaluation for service-connected prostatitis must be denied. The Board notes that at no discrete period during this appeal has the prostatitis approximated the criteria for a higher rating. Increased (Compensable) Evaluation for a History of Otitis Media and Otitis Externa The Board observes that, effective June 10, 1999, the schedular criteria for the evaluation of service-connected ear disorders/hearing loss underwent revision. Where a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant must apply, unless Congress or the Secretary provides otherwise. VAOPGCPREC 3-2000. However, if the newer regulations are more favorable to the claimant, they can only be applied for the period following the effective date of those regulations. As there is no indication that the Secretary has precluded application of either the "old" or "amended" version of the pertinent regulations, due process considerations dictate that the Veteran's claim for an increased evaluation for a service-connected history of otitis media and otitis externa be evaluated under the pertinent regulations effective both before and after the June 10, 1999 changes to the rating schedule. Bernard v. Brown, 4 Vet. App. 384 (1993). The Board observes that, pursuant to those laws and regulations in effect prior to June 10, 1999, a 10 percent evaluation is warranted for chronic suppurative otitis media only during the continuance of the suppurative process. A 10 percent evaluation for otitis externa (i.e., a disease of the auditory canal) is warranted where there is evidence of swelling, or dry and scaly or serous discharge and itching requiring frequent and prolonged treatment. 38 C.F.R. § 4.87 and Part 4, Codes 6200, 6210 (effective prior to June 10, 1999). Under the current schedular criteria in effect for the evaluation of service-connected otitis media and otitis externa, a 10 percent evaluation is warranted for chronic suppurative otitis media during active suppuration, and for chronic otitis externa where there is swelling, or dry and scaly or serous discharge, with itching requiring frequent and prolonged treatment. 38 C.F.R. § 4.87 and Part 4, Codes 6200, 6210 (effective June 10, 1999). Regarding the Veteran's claim for increase for his service-connected ear disorder, the Board notes that service connection is currently in effect only for a history of otitis media and otitis externa as combined disabilities. While in the past, the Veteran has apparently experienced episodes of both otitis media and otitis externa, on VA examinations in October 1998, April 2001, June 2004 and April 2012, he has remained essentially asymptomatic in regard to the otitis media. In point of fact, as of the time of a recent VA ear, nose and throat examination in April 2012, the Veteran's external ears and ear canals were within normal limits, as were both tympanic membranes. There was no evidence of any middle ear fluid or infection, and the Veteran's mastoid bones were normal. The Board also notes that audiograms show no hearing deficits associated with otitis media. However, September 2001 private medical records from Dr. P.M. note pain and itching in the Veteran's right ear. Records from March to May 2002 showed continued problems with itching of the ears and in late March 2003, there was noted the presence of dried blood in the Veteran's right ear. Records for 2008 show continued itching symptoms. Therefore, resolving all doubt in the Veteran's favor, the Board finds that there is sufficient evidence of disease of the auditory canal, specifically itching and pain, requiring frequent and prolonged treatment, such that a 10 percent rating is warranted under 38 C.F.R. § 4.87a, Diagnostic Code 6210. The 10 percent rating is the maximum evaluation provided for under both versions of Diagnostic Code 6210. The Board notes that as the Veteran does not warrant a compensable rating for the otitis media component of his ear disability, he is not entitled to separate ratings for the current ear disorder. Rather, the Board finds he is entitled to a 10 percent rating for the combined history of otitis media/otitis externa. The Board notes that at no discrete period during this appeal has the otitis media/otitis externa approximated the criteria for a higher rating. Extraschedular Consideration The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon 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 that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. With regard to the Veteran's service-connected right knee disability, prostatitis, and otitis media and otitis externa, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned 40 percent disability rating for the right knee disorder specifically contemplate all symptoms of his right knee disability. See 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2012). The Veteran's complaints of pain, limited range of motion due to pain, and limited physical activity are also adequately contemplated by the rating schedule, and the Board points out that Diagnostic Code 5262 references "knee disability" in the general sense without specifying precise criteria. The rating criteria for the Veteran's prostatitis and otitis media and otitis externa provide for higher ratings for more severe symptomatology. The pertinent Diagnostic Codes in the present case take into account the Veteran's reported symptomatology of his service connected prostatitis and otitis media and otitis externa. These Codes acknowledge the severity of his otitis media and otitis externa, as well as his urinary frequency, leakage, and other symptomatology of his prostatitis. The Board points out that the Diagnostic Code pertaining to the prostatitis, by specifying that the disorder is to be rated under urinary frequency or infection, whichever is predominant, recognizes that the disorder will not have symptoms which fit neatly into one category, but that nevertheless the schedular criteria are for application in such cases. As the Veteran's disability picture is contemplated by the rating schedule, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the rating assigned to the Veteran's service-connected right knee disability, prostatitis, and otitis media and otitis externa present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER An evaluation in excess of 40 percent for chondromalacia patella of the right knee is denied. An evaluation in excess of 20 percent for prostatitis is denied. A 10 percent rating for a history of otitis media and otitis externa is granted, subject to provisions governing the payment of monetary benefits. REMAND While the Board regrets further delay, after review of the record, the Board finds that a remand for further development is warranted with respect to the issues of entitlement to a TDIU and the earlier effective dates. The Board observes that medical evidence pertaining to the Veteran's TDIU claim, namely, a statement from D.H., M.D. dated July 2013, has been associated with the Veteran's claims folder following the issuance of the April 2013 Supplemental Statement of the Case (SSOC), the most recent SSOC of record pertaining to this claim; the statement was not accompanied by a waiver of initial local consideration. See 38 C.F.R. §§ 19.9, 20.1304(c) (2012). Under 38 C.F.R. § 20.1304(c), additional pertinent evidence must be referred to the agency of original jurisdiction (AOJ) if such evidence is not accompanied by a waiver of AOJ jurisdiction. Accordingly, on remand, a SSOC must be issued which includes review of this evidence. As for the earlier effective date issues, the September 2004 Board remand instructed the RO to issue the Veteran a Statement of the Case. Inexplicably, the RO has not complied. Consequently, the Board must remand those issues again. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the case is REMANDED for the following action: 1. The RO should issue a Statement of the Case on the issues of entitlement to an effective date earlier than April 16, 2001 for the assignment of a 20 percent evaluation for prostatitis, and to an effective date earlier than May 14, 1998 for the assignment of a 30 percent evaluation for allergic rhinitis with sinusitis. 2. Contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his TDIU claim, to include any private and/or VA treatment. Based on his response, attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims folder. If, after making reasonable efforts to obtain any named records, VA is unable to secure same, notify the Veteran and (a) identify the specific records that are unobtainable; (b) briefly explain the efforts that were made to obtain those records; and (c) describe any further action to be taken by VA with respect to the claim. The Veteran must then be given an opportunity to respond. 3. After completing the above action and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the TDIU claim should be readjudicated. If the claim remains denied, a SSOC should be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, the issue should be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs