Citation Nr: 1330362 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 09-12 489 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for a cervical spine disability. 4. Entitlement to service connection for sinusitis. 5. Entitlement to service connection for a right knee disability. 6. Entitlement to increased initial ratings for migraine headaches, evaluated as 0 percent disabling prior to April 19, 2012, and 30 percent thereafter. 7. Entitlement to increased initial ratings for hemorrhoids, evaluated as 0 percent disabling prior to April 19, 2012, and 10 percent thereafter. 8. Entitlement to increased initial ratings for gastroesophageal reflux disease (GERD), evaluated as 0 percent disabling prior to April 19, 2012, and 10 percent thereafter. 9. Entitlement to increased initial ratings for left leg deep vein thrombosis (DVT), evaluated as 0 percent prior disabling to April 19, 2012, and 10 percent thereafter. 10. Entitlement to an initial compensable rating for bilateral plantar fasciitis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Jarrette A. Marley, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1984 to August 1984, and from September 1984 to December 2006. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. The Veteran's representative has raised the issue of entitlement to service connection for pes planus, but such issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a cervical spine disability, low back disability, sinusitis, a right knee disability, and bilateral hearing loss, and an increased initial rating for bilateral plantar fasciitis, 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. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran's favor, throughout the appeal period the Veteran's migraine headaches have been manifested by characteristic prostrating attacks occurring at least once a month over several months; very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability are not shown at any time during the appeal period. 2. Resolving all reasonable doubt in the Veteran's favor, throughout the appeal period the Veteran's hemorrhoids have been large or thrombotic with frequent recurrences; secondary anemia or fissures are not shown at any time during the appeal period. 3. Resolving all reasonable doubt in the Veteran's favor, throughout the appeal period the Veteran's GERD has been manifested by persistently recurrent epigastric distress with pyrosis and regurgitation; a symptom combination productive of considerable or severe impairment of health is not shown. 4. Resolving all reasonable doubt in the Veteran's favor, throughout the appeal period the Veteran's left leg DVT has been manifested by aching and fatigue after prolonged standing or walking; edema, pigmentation, eczema, ulceration, and induration are not shown. CONCLUSIONS OF LAW 1. Throughout the appeal period, the criteria for a 30 percent rating, but no higher, is warranted for the Veteran's migraine headaches. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.124a, Diagnostic Code (Code) 8100 (2012). 2. Throughout the appeal period, the criteria for a 10 percent rating, but no higher, is warranted for the Veteran's hemorrhoids. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.114, Code 7336 (2012). 3. Throughout the appeal period, the criteria for a 10 percent rating, but no higher, is warranted for the Veteran's GERD. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.20, 4.114, Code 7346 (2012). 4. Throughout the appeal period, the criteria for a 10 percent rating, but no higher, is warranted for the Veteran's left leg DVT. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.20, 4.104, Code 7121 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VC The 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)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). Regarding the Veteran's claims for increased initial ratings, as the September 2007 rating decision on appeal granted service connection and assigned disability ratings and effective dates for the awards, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service connection is awarded). A March 2009 statement of the case (SOC) provided notice on the "downstream" issues of entitlement to increased initial ratings; and a December 2012 supplemental SOC (SSOC) readjudicated the matters. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has had ample opportunity to respond and/or supplement the record. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008); see also Shinseki v. Sanders, 556 U.S. 396 (2009) (discussing the rule of prejudicial error). Thus, VA's duty to notify in this case has been satisfied. The Veteran's pertinent treatment records have been secured. The RO arranged for VA examinations in October 2006 (with a September 2007 addendum report) and April 2012. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Therefore, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374; Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all of the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that 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 claim and what evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Migraine Headaches Migraine headaches are rated under Code 8100, which provides that migraines resulting in characteristic prostrating attacks averaging one in two months over the last several months warrant a 10 percent rating. Migraines resulting in characteristic prostrating attacks occurring on an average once a month over the last several months warrant a 30 percent rating. Migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability warrant a (maximum) 50 percent rating. 38 C.F.R. § 4.124a, Code 8100. Historically, a September 2007 rating decision granted service connection for migraine headaches, rated noncompensable, effective January 1, 2007. An interim, December 2012 rating decision, granted an increased 30 percent rating for the Veteran's service-connected migraine headaches, effective April 19, 2012. On October 2006 pre-discharge VA general examination, the Veteran reported headaches once a week, usually in the afternoon or evenings, and accompanied by nausea and photophobia. He indicated that they usually last about six hours with medication. In a September 2007 VA addendum report, the Veteran was diagnosed with common migraines, sporadic, and treatable with medication. It was noted that the migraines cause him to have increased absences from work. Lyster Army Hospital treatment records include a January 2007 report noting the Veteran's complaint of a dull headache. A February 2009 report noted his complaint of a headache. In his February 2008 notice of disagreement and April 2009 VA Form 9, the Veteran related that he has migraine headaches three times a month that causes him to remain in his bed with no lights on and no noise. On April 2012 VA examination, the Veteran reported he has headaches two to three times per month, with pulsating or throbbing head pain on both sides of his head, and worsened with physical activity. The headaches are also manifested by nausea, changes in vision, and sensitivity to light and sound. The Veteran takes medication for the headaches at the onset, relieving his headache in two to three hours. His head pain typically lasts less than one day. The examiner checked off the box indicating very frequent prostrating and prolonged attacks of migraine headache pain. There was no reconciliation of this response with the report that headaches last for less than one day and occur only 2 or 3 times per month. It was noted that when the headaches occur at work, he has to stop working and retires to a quiet room with no activities, no light and no sound. Following a review of the evidence of record, the Board finds that the Veteran's migraine headaches warrant a rating of 30 percent throughout the appeal period. The evidence shows that the Veteran has consistently stated that he has migraine headaches approximately two to four times per month, characterized by intense pain, sensitivity to light, and sensitivity to sound, with occasional nausea and changes in vision, and lasting two to six hours. The Board finds such symptomatology more nearly approximates the criteria for a 30 percent disability rating. However, based on the evidence above, the Board finds that an evaluation in excess of 30 percent, to include "staged" ratings, is not warranted for any period of the appeal. While the evidence shows the Veteran experiences frequent prostrating headaches, it does not show that the headaches are completely prostrating and prolonged attacks productive of severe economic inadaptability. The Veteran reported (on September 2007 VA addendum report and on April 2012 VA examination) that his migraines cause him to have increased absences from work, and that when they occur while working, he has to stop working. While the Veteran's migraine headaches have reportedly caused him to miss some time from work and be less productive at work due to his headaches, the evidence does not show they have produced severe economic inadaptability. Notably, the record reflects that the Veteran is currently employed as a manager, and is thus able to not only handle his own duties and responsibilities of his job, but also able to handle and oversee the duties and responsibilities of others. See April 2012 VA examination regarding his left leg DVT. Such does not support a disability picture of severe economic inadaptability. Hence, the schedular criteria for the next higher (50 percent) rating for migraine headaches are not met. Hemorrhoids Hemorrhoids are rated under 38 C.F.R. § 4.114, Code 7336, which provides for a 0 percent rating for mild or moderate hemorrhoids. A 10 percent rating is warranted for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, Code 7336. The schedular criteria under Code 7336 are in the conjunctive, i.e., both persistent bleeding and either anemia or fissures must be shown for the criteria for a 20 percent rating to be met. See Camacho v. Nicholson, 21 Vet. App. 360, 363-64 (2007). Historically, a September 2007 rating decision granted service connection for hemorrhoids, rated noncompensable, effective January 1, 2007. An interim, December 2012 rating decision, granted an increased 10 percent rating for the Veteran's service-connected hemorrhoids, effective April 19, 2012. On October 2006 pre-discharge VA general examination, the Veteran reported that the treatment for his hemorrhoids includes stool softeners. On physical examination, there was evidence of external hemorrhoids with bleeding and thrombosis. There was no evidence of prolapse, fissures or fistula. In a September 2007 VA addendum report, the Veteran was diagnosed with recurring thrombosing hemorrhoids. It was reported that the disability causes him to have increased absences from work. In his February 2008 notice of disagreement and April 2009 VA Form 9, the Veteran reported that his hemorrhoids are large and painful, and that he has blood most of the time. Furthermore, they are not reduced in size and they flare-up once every other month. On April 2012 VA examination, the Veteran reported that he has had numerous episodes of thrombosed hemorrhoids requiring procedures. He also indicated he has had a banding procedure (in 2010). His symptoms are ongoing with painful defecation with bleeding on bowel movements. Physical activity worsens the hemorrhoids and pain. His treatment includes daily topical cream and a suppository for flare-ups, which occur approximately two times per month for a total of about two weeks per month. It was noted that the Veteran had large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. On physical examination, multiple well-healed scars from external hemorrhoid banding procedure as well as from multiple incisions from removal of thrombosed hemorrhoids were found. It was also noted he had prolapsing internal hemorrhoids of moderate size. It was opined that his hemorrhoids did not impact his ability to work. Following a review of the evidence of record, the Board finds that the Veteran's hemorrhoids warrant a rating of 10 percent throughout the appeal period. The evidence shows that in a September 2007 VA addendum report, the Veteran was diagnosed with recurring thrombosing hemorrhoids. Moreover, the record also includes the Veteran's complaint that the hemorrhoids are large, and such was found on April 2012 VA examination. Hence, the criteria for a 10 percent disability rating are met. However, based on the evidence above, the Board finds that an evaluation in excess of 10 percent, to include "staged" ratings, is not warranted for any period of the appeal. While the evidence shows the Veteran may experience persistent bleeding, there is no evidence of anemia or fissures. As noted above, the schedular criteria under Code 7336 require both persistent bleeding and either anemia or fissures for a 20 percent rating to be met. On April 2012 VA examination, laboratory testing did not reveal anemia, and there is no evidence, or complaint, of any fissures. Accordingly, the schedular criteria for the next higher (20 percent) rating for hemorrhoids are not met. GERD The schedule of ratings for the digestive system provides that ratings under Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability picture warrants such elevation. 38 C.F.R. § 4.114. There is no specific diagnostic code for GERD; it is rated, based on similarity of symptoms, as hiatal hernia. When a veteran is diagnosed with an unlisted condition, it must be rated under an analogous diagnostic code. 38 C.F.R. §§ 4.20, 4.27. Under Code 7346 (for hiatal hernia), a 10 percent rating is warranted when there are 2 or more of the symptoms in the criteria for a 30 percent rating, of less severity than the symptoms warranting a 30 percent rating. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. Historically, a September 2007 rating decision granted service connection for GERD, rated noncompensable, effective January 1, 2007. An interim, December 2012 rating decision, granted an increased 10 percent rating for the Veteran's service-connected GERD, effective April 19, 2012. On October 2006 pre-discharge VA general examination, the Veteran reported that the treatment for his GERD includes over-the-counter antacids. The examiner noted that he suspected the Veteran's GERD is actually gastritis medicamentosa. On review of the abdomen/gastrointestinal system, it was noted the Veteran's symptoms included nausea, indigestion and heartburn; dysphagia, regurgitation were not noted. On physical examination, bowel sounds were normal, and there was no evidence of any tenderness or other abnormality, including abdominal guarding. In a September 2007 VA addendum report, the Veteran was diagnosed with gastritis medicamentosa, GERD ruled out by upper gastrointestinal series, with no effect on work. In his February 2008 notice of disagreement and April 2009 VA Form 9, the Veteran reported that his epigastric distress includes regurgitation and shoulder pain. Lyster Army Hospital treatment records include a February 2009 report noting the Veteran's gastrointestinal symptoms include minimal diarrhea; nausea and vomiting were denied. On April 2012 VA examination, the Veteran reported that takes six to eight Rolaids tablets daily for his GERD. He indicated he experiences persistently recurrent epigastric distress, pyrosis, reflux, regurgitation, sleep disturbance due to his GERD, recurrent nausea, and transient vomiting. Laboratory testing was negative for any abnormalities. It was noted that there was no evidence of GERD on current upper gastrointestinal series testing. The examiner opined that the Veteran's GERD did not impact his ability to work. Following a review of the evidence of record, the Board finds that the Veteran's GERD warrants a rating of 10 percent throughout the appeal period. The evidence shows that on October 2006 pre-discharge VA general examination, the Veteran reported his symptoms included nausea, indigestion and heartburn. Moreover, in his February 2008 notice of disagreement and April 2009 VA Form 9, the Veteran reported that his epigastric distress included regurgitation and shoulder pain. While the Board finds the Veteran's report of shoulder pain related to his service-connected GERD to be highly questionable, as the Veteran has reported his GERD includes regurgitation and pyrosis, symptoms which he is capable of reporting, the Board concludes the criteria for a 10 percent disability rating are met. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, based on the evidence above, the Board finds that an evaluation in excess of 10 percent, to include "staged" ratings, is not warranted for any period of the appeal. As noted above, while the evidence shows the Veteran's report of shoulder pain due to his service-connected GERD is suspicious. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). However, for the purpose of this appeal, even assuming for the sake of argument that he experiences such and it is related to his GERD, the evidence does not suggest that his GERD has resulted in considerable impairment of health. He describes symptoms that appear to be mild in severity. Notably, the April 2012 VA examiner found his GERD had no effect on his ability to work. Also, recent upper gastrointestinal series testing was negative for evidence of GERD. Consequently, the criteria for the next higher, 30 percent, rating are not met (or approximated). The Board notes that there are complaints of vomiting. However, there is no indication in the clinical data of other symptoms associated with an even higher (60 percent) rating (i.e., material weight loss, hematemesis, or melena with moderate anemia), and such symptoms are not alleged. Consequently, a rating for GERD in excess of 10 percent is not warranted. The Board has also considered whether a higher rating under the gastritis Diagnostic Code could be assigned. Under Diagnostic Code 7307, chronic gastritis identified by gastroscope with multiple small eroded or ulcerated areas and symptoms warrants a 30 percent rating. A 60 percent rating is warranted for severe hemorrhages or large ulcerated or eroded areas. 38 C.F.R. § 4.114. The Board notes, however, that the upper GI radiograph studies in May 2012 showed a normal stomach, duodenum and loop. The Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of his GERD. Accordingly, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 10 percent for GERD. Left Leg DVT Under Code 7121, post-phlebitic syndrome of any etiology provides a 0 percent rating for asymptomatic palpable or visible varicose veins. A 10 percent rating is warranted for intermittent edema of an extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. A 20 percent rating is warranted for persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating is warranted for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent rating is warranted for persistent edema or subcutaneous indurations, stasis pigmentation or eczema, and persistent ulceration. A (maximum) 100 percent rating is warranted for massive board-like edema with constant pain at rest. 38 C.F.R. § 4.104, Code 7121. Historically, a September 2007 rating decision granted service connection for left leg DVT (secondary to his open reduction and internal fixation of the left knee for medial tibial plateau fracture), rated noncompensable, effective January 1, 2007. An interim, December 2012 rating decision, granted an increased 10 percent rating for the Veteran's service-connected left leg DVT, effective April 19, 2012. In a September 2007 VA addendum report, the Veteran was diagnosed with left leg DVT following open reduction and internal fixation of the left tibial fracture. In his February 2008 notice of disagreement and April 2009 VA Form 9, the Veteran reported that his left leg DVT is manifested by itching and fatigue, indicating that he has to elevate his leg after he gets home from doing any walking or standing. On April 2012 VA examination, it was noted the Veteran's symptoms include aching pain and fatigue in his left leg after prolonged standing or walking, relieved by elevation of the leg. After physical examination of the Veteran, the examiner noted that physical examination was negative, with no evidence of varicose veins, stasis ulcer, pigmentation, edema, or tenderness. There was also no evidence of post-phlebitic syndrome or signs of acute DVT. Nonetheless, a diagnosis of left leg DVT was provided. Following a review of the evidence of record, the Board finds that the Veteran's left leg DVT warrants a rating of 10 percent throughout the appeal period. As the Veteran has reported his left leg DVT is manifested by aching pain and fatigue that are relieved by elevation of his leg, symptoms which he is capable of reporting, the Board concludes the criteria for a 10 percent disability rating are met. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, based on the evidence above, the Board finds that an evaluation in excess of 10 percent, to include "staged" ratings, is not warranted for any period of the appeal. As there is no evidence of edema or any of the other criteria as to warrant a rating in excess of 10 percent, and the Veteran has reported that his symptoms are completely relieved by elevation of his left leg, the Board finds that a rating in excess of 10 percent for left leg DVT is not warranted. Accordingly, the schedular criteria for the next higher (20 percent) rating for the Veteran's left leg DVT are not met. Other Considerations The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology from his headaches, hemorrhoids, left leg DVT, and GERD, and provide for additional or more severe symptoms than currently shown by the evidence; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. Finally, as the record shows that the Veteran is employed (on April 2012 VA examination as a manager at a coffee store), and has been throughout the appeal period, the matter of entitlement to a total rating based on individual unemployability is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER From January 1, 2007, a 30 percent rating is granted for the Veteran's migraine headaches, subject to law and regulations governing the effective date of an award of monetary compensation. An evaluation in excess of 30 percent for migraine headaches is denied. From January 1, 2007, a 10 percent rating is granted for the Veteran's hemorrhoids, subject to law and regulations governing the effective date of an award of monetary compensation. An evaluation in excess of 10 percent for hemorrhoids is denied. From January 1, 2007, a 10 percent rating is granted for the Veteran's GERD, subject to law and regulations governing the effective date of an award of monetary compensation. An evaluation in excess of 10 percent for GERD is denied. From January 1, 2007, a 10 percent rating is granted for left leg DVT, subject to law and regulations governing the effective date of an award of monetary compensation. An evaluation in excess of 10 percent for left leg DVT is denied. REMAND Regarding the Veteran's claim for service connection for bilateral hearing loss, after a review of the claims file, the Board finds that additional development is necessary for proper adjudication of the claim. Hearing loss disability is defined by regulation. For the purpose of applying the laws administered by the VA, impaired hearing will be considered 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. 38 C.F.R. § 4.85 outlines guidelines for the conduct of hearing acuity evaluations. The Court has held that the threshold for normal hearing is from zero to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Veteran's service treatment records include a March 2006 audiogram that found his puretone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 20 5 LEFT 45 55 45 35 25 Such findings appear to show, at least, evidence of left ear hearing loss by VA standards, as well as some hearing loss in the right ear. Id. However, an October 2006 VA examination, prior to service discharge, showed hearing within normal limits for VA purposes. As it has been 7 years since that examination and due to the conflicting nature of the March 2006 and October 2006 audiometric testing, the Board finds that the Veteran should be afforded a VA examination to determine the existence of a bilateral hearing loss disability and if necessary, to obtain an opinion as to its relationship to service. Regarding the Veteran's claim for service connection for a right knee disability, the Board notes that the Veteran's service treatment records include various reports noting the Veteran's complaints of bilateral knee pain, and diagnosing bilateral patellofemoral syndrome. On October 2006 pre-discharge VA general examination, it was noted that the Veteran had chronic bilateral knee pain of uncertain etiology. In a September 2007 VA addendum report, the Veteran was diagnosed with bilateral knee pain, no bony pathology identified. Significantly, the Veteran's claims file was not available at the time of the October 2006 VA examination. Hence, it does not appear that the examination report was prepared based on a full review of the pertinent medical history. Accordingly, the Board finds that the matter must be remanded to obtain a new VA examination and opinion concerning the right knee disability. Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). Regarding the Veteran's claim for service connection for a low back disability and cervical spine disability, the Veteran's service treatment records include an August 26, 2003 report diagnosing lumbago, and opining that his back pain is consistent with a herniated nucleus pulposis, likely at T7. His service treatment records also include complaints of lower back pain and an assessment of lower back sprain. See, e.g., June 10, 2004 service treatment report. An August 19, 2002 report noted his complaint of neck pain and spasm, present for two years, increased over the last four days; physical examination revealed tenderness to palpation over the posterior neck and upper back. Notably, on October 2006 pre-discharge VA general examination, physical examination revealed a normal spine. In a September 2007 VA addendum report, the Veteran was diagnosed with musculoskeletal lower back pain without disc disease and intermittent cervical pain without bony pathology or disc disease identified. However, an October 2006 VA cervical spine x-ray revealed narrowed disc at C5-C6 with minimal uncovertebral spurring. Accordingly, the Board finds that the matters must be remanded to obtain a new VA examination to determine whether the Veteran suffers from cervical spine and low back disabilities that are related to service. Id. Regarding the Veteran's claim for sinusitis, the Veteran's service treatment records show multiple diagnoses of sinusitis. See, e.g., January 10, 2002 report providing an assessment of acute sinusitis; May 3, 2006 report providing an assessment of sinusitis. Lyster Army Hospital post-service treatment records also include a diagnosis of allergic rhinitis and acute sinusitis. See February 14, 2007 report; September 9, 2008 report. However, in a September 2007 VA addendum report, the Veteran was diagnosed with seasonable rhinitis/sinusitis, suggesting that the complaints and treatment during service were acute episodes, but adequate rationale was not provided. In light of the foregoing, the Board finds that the matter must be remanded to obtain a new VA examination as to the nature of the Veteran's claimed sinusitis disability. Barr v. Nicholson, 21 Vet. App. 303 (2007). Finally, the Board finds that additional development is necessary for proper adjudication of the Veteran's claim for an increased rating for bilateral plantar fasciitis. The disability is rated (curiously) under Diagnostic Code 5099-5020 (by analogy for synovitis, as opposed to being rated under the rating criteria for feet. Nonetheless, on October 2006 pre-discharge VA general examination, it was noted that the Veteran's bilateral plantar fasciitis was due to his unequal leg length which was due to his service-connected left knee status post open reduction and internal fixation of the left medial tibial plateau disability, and resulted in bilateral foot pain and fatigability. Physical examination revealed bilateral foot pain over the mid-arch on pressure. On April 2012 VA examination, while a diagnosis of bilateral plantar fasciitis was provided, the examination report also includes a diagnosis of bilateral pes planus and small plantar calcaneal tuberosities. It was further noted that the Veteran is a manager at a store and about four days of a week, his employees have to push him around in a chair due to his inability to ambulate secondary to foot pain. Based on the examination report, it is unclear what is the source of the Veteran's bilateral foot pain (i.e., the service-connected bilateral plantar fasciitis, or nonservice-connected foot disabilities). In light of the above, the Board finds that another VA examination in this matter is necessary. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide the names, addresses, and approximate dates of all health care providers, both VA and private, who have provided treatment since his separation from service for his claimed hearing loss, low back, cervical spine, sinusitis or rhinitis, right knee, and foot disabilities. After securing any necessary releases, the RO/AMC should request any records identified which are not duplicates of those contained in the claims file. If any requested records are unavailable, then the file should be annotated as such and the Veteran should be so notified. 2. After completion of the foregoing and association of any outstanding evidence with the claims file, schedule the Veteran for a VA audiology examination to determine whether the Veteran suffers from a current hearing loss disability, and if so, whether such is related to service. The claims file must be reviewed by the examiner in conjunction with the examination. If current hearing loss disability of either ear is identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the his hearing loss arose during service or is otherwise related to service, to include noise exposure therein. In rendering the opinion, the examiner should address the significance of the March 2006 audiogram. The reasoning for the opinion expressed should be provided. 3. Schedule the Veteran for an orthopedic examination to determine whether the Veteran suffers from current right knee, cervical spine and low back disabilities and if so, whether such is/are related to service. The claims file must be reviewed by the examiner in conjunction with the examination. All tests and studies deemed necessary should be conducted and the results reported. Following review of the record and examination of the Veteran, the examiner should provide an opinion that responds to the following: a) Please diagnose the Veteran's current right knee, cervical spine and/or low back disabilities, if extant. b) As to each disability diagnosed, please indicate whether it is at least as likely as not (50 percent probability or greater) that the disability arose during service or is otherwise etiologically related to service. Please explain the reasoning for the conclusions, to include reference to the in-service right knee, back and neck complaints. c) If the examiner concludes the Veteran does not have a diagnosed right knee, cervical spine, and/or lumbar spine disability, please also address the following: 1) Explain how the Veteran was diagnosed with bilateral patellofemoral syndrome in service but now has no right knee disability. 2) Explain how the Veteran now has no cervical spine disability when an October 2006 VA cervical spine x-ray revealed narrowed disc at C5-6 with minimal uncovertebral spurring. 3) Explain how the Veteran was diagnosed with lumbago and lower back sprain in service but now has no lumbar spine disability. 4. Schedule the Veteran for a sinus/rhinitis examination. The claims file must be reviewed by the examiner in conjunction with the examination. All tests and studies deemed necessary should be conducted and the results reported. Following review of the record and examination of the Veteran, the examiner should indicate whether the Veteran suffers from a chronic sinus or rhinitis disability. For any sinus or rhinitis disabilities identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that such disorder had its onset during service or is otherwise etiologically related to service. In rendering this opinion the examiner should address the significance of the sinus and rhinitis symptoms documented in the service treatment records. The examiner should provide the reasoning for the conclusions expressed. 5. Schedule the Veteran for a VA foot examination to determine the current severity of his bilateral plantar fasciitis. All tests or studies deemed necessary should be conducted, and the results should be reported in detail. The examiner should describe all symptoms related to the Veteran's bilateral plantar fasciitis. To the extent possible, the examiner should attempt to disassociate any foot symptoms solely attributable to nonservice connected foot disabilities. 6. After the above has been completed to the extent possible, the RO/AMC should readjudicate the issues on appeal. If the benefits sought on appeal remain denied, the Veteran and his representative should be issued a supplemental statement of the case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board if in order. 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). ______________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs