Citation Nr: 0211489 Decision Date: 09/06/02 Archive Date: 09/09/02 DOCKET NO. 93-24 187 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUES 1. Entitlement to service connection for a left hip disability. 2. Entitlement to service connection for a back disability. 3. Entitlement to service connection for pes cavus of the left foot. 4. Entitlement to a compensable evaluation for sinusitis for the period January 17, 1978, to March 19, 1992. 5. Entitlement to an extension of a temporary total disability rating based on the need for convalescence for sinusitis beyond November 30, 1992. 6. Entitlement to an evaluation in excess of 10 percent for sinusitis for the period May 5 to September 8, 1992, and for the period beginning December 1, 1992. 7. Entitlement to an evaluation in excess of 10 percent for callosities of the plantar surface of the left heel for the period beginning June 6, 1989. 8. Entitlement to a compensable evaluation based on multiple, noncompensable service-connected disabilities under 38 C.F.R. § 3.324, for the period January 17, 1978 to June 6, 1989. (The issue of entitlement to vocational rehabilitation training under Chapter 31, Title 38, United States Code is the subject of a separate Board decision). REPRESENTATION Appellant represented by: Sean Kendall, Attorney-at-Law WITNESSES AT HEARINGS ON APPEAL The veteran ATTORNEY FOR THE BOARD J. M. Daley, Counsel INTRODUCTION The veteran had active service from September 1974 to January 1978. This matter is before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO), located in Cheyenne, Wyoming. A June 1995 decision of the Board denied, inter alia, secondary service connection for left hip and back disabilities, and failed to address entitlement to vocational rehabilitation benefits. The veteran appealed to the United States Court of Appeals for Veterans Claims (Court).. In a Memorandum Decision issued in September 1997, the Court vacated those portions of the Board's June 1995 decision and remanded for further action. In a December 1999 decision, the Board, inter alia, denied a compensable evaluation for sinusitis for the period January 17, 1978, to March 19, 1992, and denied an extension of a total disability rating (based on sinus operations performed by VA in September and October 1992) for convalescence beyond November 30, 1992. The veteran appealed those matters to the Court. In an Order dated in October 2001, the Court vacated solely the portion of the Board's December 1999 decision that denied a compensable evaluation for sinusitis for the period January 17, 1978, to March 18, 1992, and that denied an extension of a total disability rating (based on sinus operations performed by VA in September and October 1992) for convalescence beyond November 30, 1992. Those issues were remanded for Board consideration and action consistent with the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). In its December 1999 remand, the Board directed the RO to issue a statement of the case relevant to the issue of entitlement to an evaluation for sinusitis in excess of 10 percent for the period May 5, 1992, to September 8, 1992, and beginning December 1, 1992. A statement of the case was issued September 13, 2000, and the record reflects receipt of a Form 9 containing arguments relevant to the severity of sinusitis, dated September 13, 2000, and stamped as received September 19, 2000. As such, this issue now properly comes before the Board. The Board notes that entitlement to an effective date earlier than June 6, 1989, for a compensable evaluation for callosities of the plantar surface of the left heel was denied in a Board decision dated in June 1995. The matter was not appealed to the Court at that time, and remained unaffected by the Court's October 2001 Order. The Board recognizes that in his January 2002 statement, the veteran's attorney has again raised the issue. However, the Board does not have jurisdiction to again review the question at this time. See 38 U.S.C.A. §§ 7104, 7105 (West 1991 & Supp. 2001). By rating decision dated in June 2001, the RO granted service connection for residuals of a left knee injury and assigned a noncompensable rating, effective August 23, 1990. Such represented a full grant of the benefit sought, i.e. service connection. In a statement received in March 2002, the veteran's attorney has expressed disagreement with the effective date and percentage rating assigned to his left knee disability. In the Remand portion of this decision such matters are directed to the RO for issuance of a statement of the case. However, the Board notes that as no additional compensation benefits would be available for the left knee under 38 U.S.C.A. § 1151 (West Supp. 2001), the service connection grant rendered the veteran's claim pursuant to 38 U.S.C.A. § 1151 moot and such basis of entitlement will not be discussed further herein. See 38 U.S.C.A. §§ 7104, 7105(d); 38 C.F.R. § 20.101 (1999); Waterhouse v. Principi, 3 Vet. App. 473 (1992); Mokal v. Derwinski, 1 Vet. App. 12 (1990). The Board also notes that in a January 2002 statement, the veteran's attorney raises claims of entitlement to temporary total ratings pursuant to 38 C.F.R. § 4.29 (2001) or 38 C.F.R. § 4.30 (2001) based on hospitalization and/or convalescence periods related to the left heel, left knee and sepsis claimed as secondary to sinusitis. Such matters are referred to the RO for initial consideration and appropriate action. Finally, the Board acknowledges the veteran's recent correspondence, to include a Form 9 dated in December 2001 and received in January 2002, in which he purports to submit general notices of disagreement and substantive appeals on "all outstanding or open) adjudications....and all of the awards, denial of awards, and those claims, formal and informal, that the VA has failed to adjudicate or has denied that may be open since January 16, 1978..." The Board emphasizes, however, that the Board's jurisdiction is governed by clear statutory and regulatory procedures, the details of which the veteran and his attorney have recently been notified. In particular, the veteran's attention is directed to provisions relevant to the time limits for initiating and perfecting an appeal. See 38 C.F.R. § 20.302 (2001). Also, the veteran is advised that 38 C.F.R. § 19.26 (2001) provides that when a notice of disagreement is received following a multiple-issue determination and it is not clear which issue, or issues, the claimant desires to appeal, clarification sufficient to identify the issue, or issues, being appealed should be requested from the claimant or his or her representative/attorney. Thus, to the extent the veteran desires his recent correspondence to serve as a notice of disagreement on any issue not addressed in some respect herein, he should advise the RO as to the specific rating action and specific matter(s) he intends to pursue on appeal to the Board. The issue of entitlement to a compensable evaluation based on multiple, noncompensable service-connected disabilities under 38 C.F.R. § 3.324, for the period January 17, 1978, to June 6, 1989, is addressed in the remand portion of this decision. FINDINGS OF FACT 1. All information and evidence necessary for an equitable disposition of the issues decided herein have been obtained. 2. A left hip disorder, diagnosed as persistent trocanter bursitis, resulted from an altered gait caused by the veteran's service-connected left heel disability. 3. The veteran has no chronic low back disability. 4. The veteran does not have pes cavus of the left foot. 5. For the period January 17, 1978, to March 19, 1992, sinusitis was manifested by X-ray findings and infrequent episodes productive of only mild disability. 6. For the period March 20, 1992, to October 7, 1996, the veteran's sinusitis was manifested by moderate symptomatology characterized by discharge or crusting or scabbing and infrequent headaches; he did not manifest severe symptomatology with frequently incapacitating recurrences, severe and frequent headaches with purulent discharge or crusting reflecting purulence. 7. From October 7, 1996, the veteran's sinusitis was manifested by moderate symptomatology characterized by discharge or crusting or scabbing and infrequent headaches, or by less than two incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment, or less than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 8. Subsequent to his September and October 1992 sinus surgeries, the veteran did not require convalescence beyond November 30, 1992. 9. For the period beginning June 6, 1989, callosities of the plantar surface of the left heel with plantar fasciitis results in pain, particularly with weight bearing, and is productive of no more than mild impairment. CONCLUSIONS OF LAW 1. A left hip disability is proximately due to service- connected disability. 38 U.S.C.A. § 1110 (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.303, 3.310(a) (2001). 2. A back disability was not incurred in or aggravated by active service and is not proximately due to or the result of service-connected disability. 38 U.S.C.A. § 1110 (West Supp. 2001); 38 C.F.R. §§ 3.303, 3.310(a) (2001). 3. Pes cavus of the left foot was not incurred in or aggravated by active service and is not proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1110 (West Supp. 2001); 38 C.F.R. §§ 3.303, 3.310(a) (2001). 4. The criteria for entitlement to a compensable evaluation for sinusitis for the period January 17, 1978, to March 19, 1992, have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.97, Diagnostic Code 6513 (1996). 5. The criteria for an evaluation in excess of 10 percent for sinusitis for the period May 5 to September 8, 1992, and for the period beginning December 1, 1992, have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.97, Diagnostic Code 6513 (effective prior and subsequent to October 7, 1996). 6. The criteria for the extension of a temporary total disability rating based on convalescence for sinusitis, beyond November 30, 1992, have not been met. 38 C.F.R. § 4.30 (2001). 7. The criteria for entitlement to an evaluation in excess of 10 percent for callosities of the plantar surface of the left heel for the period beginning June 6, 1989 have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5284 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA During the pendency of the veteran's appeal, the VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law. In addition, regulations implementing the VCAA (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West Supp. 2001)), were published at 66 Fed. Reg. 45,620, 45,630-32 (August 29, 2001) (to be codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326). For the purposes of this decision, the Board will assume that the VCAA and the implementing regulations, to include the notice and duty to assist provisions, are applicable to the veteran's claims. The Act and the implementing regulations essentially eliminate the requirement that a claimant submit evidence of a well-grounded claim, and provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA and the implementing regulations were in effect when the RO most recently considered the veteran's claims. The record reflects that the veteran has been notified of the law and regulations governing entitlement to service connection, the evaluation of sinusitis (to include the regulatory changes made during the pendency of his appeal) and foot disorders, and the criteria for entitlement to extensions of temporary total ratings based on convalescence. He has also been notified of the evidence considered by the RO and the reasons for its determinations. In addition the RO has afforded the veteran appropriate examinations and the record contains sufficient medical evidence upon which to decide the veteran's claims. The Board notes that the veteran, via his attorney, has recently submitted additional argument and prescription records pertinent to the sinusitis rating issue. Also, additional evidence pertinent to other issues on appeal has been associated with the claims file since the last relevant statement of the case or supplemental statement of the case was issued. However, 38 C.F.R. § 20.1304 (2001) has been amended to eliminate the requirement that a supplemental statement of the case be issued addressing evidence received after the certification of the appeal. See 67 Fed. Reg. 3099, 3105-3106 (January 23, 2002). All pertinent evidence of record has been considered in connection with the decisions made herein. Neither the veteran nor his appointed representative has identified any outstanding evidence or information that could be obtained to substantiate the claims decided herein. The Board is also unaware of any such outstanding evidence or information. For the above reasons, the Board finds that the facts pertinent to these claims have been properly developed and that no further action is required to comply with the VCAA or the implementing regulations. Factual Background During service the veteran was treated for upper respiratory infections and ear infections. Service medical records reflect that in September 1976, the veteran reported he had twisted his left knee with resulting internal or medial pain, stiffness, swelling and episodes of giving way. A December 1976 service entry notes a swollen right maxillary area without improvement; X-rays showed an old fracture of the nasal bones with impaction of the septum with an inability to breath adequately nasally. Symptoms included coughing, a sore throat, headaches and ear pain. On the report of medical history completed in November 1977, the veteran denied having or having had recurrent back pain. On the accompanying report of medical examination, the examining physician noted the veteran to have a history of bilateral maxillary sinusitis and a foreign body in the plantar surface of the left heel, for which surgical removal was attempted. The veteran's spine and lower extremities (other than the feet) were marked as normal. In November 1978 the veteran reported for a VA examination. He complained of continued left heel pain, resulting in an inability to walk properly. He reported that he had developed pain in his back and left hip when walking, but indicated he was able to run without any symptoms. He indicated he had missed five days' work in January due to his sinuses. X-rays revealed no sinus abnormalities and no evidence of a retained foreign body in the left heel. Examination revealed both sinus passages to be clear. The examiner noted the veteran walked with a normal gait and was not in acute distress. No diagnosis pertinent to the back or hip was offered. The only diagnosis pertinent to the left foot was retained foreign body in the left heel by history. In a rating decision dated in January 1979, the RO granted service connection for a callosity on the plantar surface of the left heel, residual to a left heel wound and assigned a noncompensable rating effective January 17, 1978. In a statement received in April 1979, the veteran indicated that the pain in his left heel had resulted in back problems due to the impact on his gait. Private treatment records from A. Rajapakse, M.D., are of record. A record dated in August 1981 reflects the veteran's complaints of a headache, listlessness and a runny nose of four days' duration; the impression was an upper respiratory infection. In March and November 1982, April 1983, and November 1984, the veteran was treated for complaints of a cold and cough. In December 1983, the veteran was seen for a congested ear. Records dated in December 1984 and from January to February 1985 show complaints of a sore throat, sinuses, and earaches of many weeks' duration. In May 1985, the veteran again complained of a sore throat, a cough and nasal drip. In September 1985 he complained of ear problems. In November 1985 he reported cold symptoms. In December 1986 he complained of earaches. In July 1988 he complained of a head and chest cold; the impression was upper respiratory infection/sinusitis. Entries dated in January 1989, March 1990, and November 1990 also show complaints of cold symptoms. A 1992 entry notes bilateral maxillary sinusitis. The veteran was usually treated with antibiotics in connection with the above. In a statement received in August 1990, the veteran again complained of back and hip pain, as well as knee pain, which he attributed to an altered gait caused by his left heel disability. At the time of VA examination conducted in October 1990, the veteran complained of increased heel pain, preventing him from walking or running. He also indicated that he had constant back pain. The veteran was observed to ambulate with a normal alternating gait and to perform requested motions such as toe and heel walking on the outer borders of his feet. The examiner noted callosities that were painful to percussion but not to palpation. Left hip flexion was noted to be painful. The examiner diagnosed a painful callosity on the plantar surface of the left heel. The examiner opined that the veteran's left knee and hip pain were not secondary to his left heel laceration and callous formation. X-rays showed pes cavus without other foot pathology. Hip X-rays were normal. In connection with such examination, the veteran indicated he had lost 65 days of work in the year prior to examination due to his left foot. In a statement dated in April 1991, A. Rajapakse, M.D. reported treatment of the veteran since 1981, most recently in November 1990. Dr. Rajapakse indicated that the veteran had been seen approximately every three-to-six months for upper respiratory infections, coughing, post-nasal drip and head and chest congestion, treated with various antibiotics and cough medication with good response. In a statement received in April 1991, the veteran reported pain in his left heel that prevented him from working. A VA outpatient record dated in July 1991 notes the veteran's complaints of left leg pain and some numbness. The physician noted that the veteran had a positive Tinel's sign at the tarsal tunnel and at the origin of the abductor hallus. The impression was that the veteran had had a complicating tarsal tunnel probably secondary to scarring and inflammation status post previous surgeries for his foreign body. Electromylogram of the lower extremity was scheduled. The September 1991 report indicates there was no evidence of tarsal tunnel compression in the medial/lateral plantar nerves. VA records dated in October 1991 note chronic plantar fasciitis. The veteran's range of foot motion was normal. He complained of hip and knee pain when walking. One impression was a probable ligament tear in the left knee. In a statement received in November 1991, the veteran indicated he had been told his left heel callous was altering his gait but that the condition would right itself over time. He continued to make arguments relating his knee, hip and back problems to his service-connected left heel residuals. In his November 1991 hearing, the veteran reiterated such arguments. A VA medical treatment entry dated in March 1992 notes bilateral maxillary sinusitis with a history of antibiotic treatment. Antibiotics were prescribed. Computerized tomography taken in May 1992 showed mild mucosal congestion in the left maxillary sinus and findings characteristic of a retention cyst on the right. Based on such findings surgery was scheduled. A July 1992 VA record notes the veteran's complaints of a foot problem creating a hip problem. It was noted that the scar tissue could be causing irritation resulting in tenderness and plantar fasciitis symptoms. Private records dated in July 1992 note electrodiagnostic testing for evaluation of tarsal tunnels. Testing revealed a prolonged latency on the left. In connection with a personal hearing in July 1992, the veteran stated he had been treated with antibiotics for his sinusitis since service discharge. He also argued that pes cavus of his left foot was caused by surgery on his left heel. September 1992 VA records note the veteran's complaints of nasal obstruction and headaches, the latter stated to get better when treated with antibiotics. Examination revealed obstruction of the left side of the nasal passages. A VA hospital summary dated in October 1992 notes that the veteran had been admitted in September for a history of sinus problems and underwent nasal septoplasty, bilateral endoscopic sinus surgery with antrostomy and ethmoidectomy. He was doing well post-operatively. A later October 1992 VA Ear, Nose and Throat clinic record indicates that there was still crust but the veteran was doing better. Another October record notes that the veteran had had soreness and excessive tenderness in his nose and underwent surgical revision of the scarring in October. The operative report notes moderately severe sinusitis. The veteran was discharged after the surgery, with instructions to follow-up. In a statement dated in March 1993, S. Suresh, M.D., reported that the veteran had had chronic maxillary sinusitis since 1975 and had been seen by various physicians and treated with antibiotics. Dr. Suresh noted the veteran had recently had surgery for sinus problems, with minimum improvement. In statements submitted in connection with his appeal, the veteran indicated that he had sought treatment for his sinuses after his October 1992 surgery but had been refused by VA. He reported being unable to work from the time of the surgery until in or around June 1994. The report of VA examination conducted in October 1994 includes note of the veteran's complaints of knee, foot, hip, back and sinus problems. Examination revealed tenderness along the plantar area. There was a full range of left hip motion with no signs of sciatic nerve involvement. The veteran reported he had worked as a locksmith since 1992, but had lost 60 days of work the year prior to examination due to problems such as his sinusitis. A July 1995 VA outpatient record notes the veteran's complaints of left foot, knee and hip pain, with a loss of sensation in his left foot and toes. A report of VA examination dated in August 1995 notes the veteran's complaints of foot pain resulting in an altered gait and associated hip and back pain. He demonstrated a full range of foot motion bilaterally. He indicated he would not be able to achieve so much movement if not for his pain medications. In August 1995, the veteran was evaluated by VA for complaints of chronic nasal obstruction, facial pain, headaches and post-nasal drip. He reported frequently needing antibiotics. The examiner noted two prior sinus surgeries. Examination revealed bilateral nasal synechia. Rhinoscopy revealed that the sinuses looked clear. X-rays were referenced as showing some mucosal thickening. A complete report of physical examination dated in August 1995 includes the veteran's complaint of constant nasal discharge, almost constant pain, pressure and tenderness over the sinus areas, and frequent infections. X-rays of the sinuses taken in September 1995 revealed moderate mucosal thickening in the left maxillary sinus, with mild changes in the anterior ethmoids. The record contains a form dated in September 1995, in which the veteran identifies himself as self-employed, working in a lock/alarm business without interruption since the 1980s. A September 1995 podiatry clinic note indicates that, in the reviewing physician's experience, the type of foot pain complained of by the veteran could change his way of walking which, in turn, would result in knee and hip pains. An October 1995 entry indicates the veteran's request to have the relationship between his foot pain, altered gait and hip problems documented; the reviewing physician, indicated the veteran's concerns were not unrealistic and that his trochanteric bursitis may be a result of chronic foot problems. A note indicates the situation was discussed with the Chief of Orthopedics. In connection with a hearing conducted in March 1996, the veteran reported foot pain resulting in an inability to walk for any distance and thus interfering with his ability to work. He indicated he had had consistent treatment for his sinus problems during service and thereafter. He also offered argument relevant to the way his claims had been handled. In connection with a vocational rehabilitation hearing conducted in May 1996, the veteran indicated he controlled his sinusitis by medication. VA testing in September 1996 revealed fairly severe mucoperiosteal thickening in the left maxillary antrum. Records dated in 1996 indicate that further sinus surgery was suggested. At the time of examination conducted in October 1996, the veteran complained of being able to walk only 1/2 mile before his foot, legs and back would hurt. The examiner noted the presence of varus and valgus on the left, and plantar fasciitis in both feet. There was no note of any pes cavus. The impression was that the veteran's hip and back pains were secondary to rotational problems of the foot and ankle. In late April 1997, the veteran presented with sinus complaints of three days' duration; antibiotics were prescribed. A Primary Care Clinic screening note and outpatient records dated in June 1997 indicate the veteran was on a two-week course of antibiotics for a sinus infection. In August 1997, the veteran again testified at a personal hearing. He stated he had been unemployed for over a year after his October 1992 sinus surgery. His spouse testified she had attended nursing school for several years and had worked as a nursing aid. She also reported that the veteran had been treated with antibiotics for sinus problems for many years. Two witnesses appeared and testified as to knowledge of the veteran's constant nasal discharge, to include for weeks after his October 1992 surgery. In April 1998, the veteran complained of a sinusitis flare-up lasting 36 hours, characterized by an ear ache, a drippy nose and discharge; antibiotics were prescribed at a VA facility. August and September 1998 VA progress reports note the veteran was taking antibiotics for sinus flare-ups and using a nasal spray. In December 1998, the veteran received antibiotics for sinusitis, manifested by drainage. A VA outpatient record dated in June 1999 notes chronic sinusitis; the veteran was given a 10-day course of antibiotics. The veteran testified before the undersigned in July 1999. He indicated he first developed hip and back pain in service. The veteran testified relevant to the procedural history of his claims. He indicated he had been taking Sulfa about six times per year for his sinuses after service and that every other month he received antibiotic treatment. He reported symptoms such as fever and bloodshot eyes, pain, headaches and constant nasal discharge approximately every two months. VA X-rays taken in November 2000 showed moderate degenerative changes of the left knee, mild-to-moderate degenerative changes in the left hip, and mild degenerative changes in the left foot. A fee-basis clinical examination of the veteran was conducted at that time by M. Rangitsch, M.D., who noted extensive review of the veteran's file. The veteran's history of lower extremity problems, to include knee surgery, was noted. Dr. Rangitsch also noted the veteran to be carrying a diagnosis of "tarsal tunnel syndrome with pes cavus." Dr. Rangitsch noted chronic antalgic mannerisms in the veteran, with difficulty weight bearing. There was evidence of exquisite tenderness to palpation near the calcaneus, opined to be out of proportion to examination. There was otherwise noted to be a full range of foot and ankle motion without deformity. The veteran's hip motion and knee motion were full. He had full motor strength, sensation and deep tendon reflexes. Prior foot and ankle X-rays were noted to have been negative for abnormal findings near the calcaneus. The assessment was status post foreign body to the left heel with subsequent multiple surgeries and now- apparent medial plantar nerve neuroma and no objective findings relevant to the back and hip. Dr. Rangitsch stated that the diagnosis relevant to the left foot was a medial plantar neuroma. Dr. Rangitsch found no relation of left hip and back complaints to the left foot and ankle and opined that "if somebody is not bearing weight on their left foot, this would tend to decrease the amount of wear and tear on the left knee/hip area. A February 2001 report of VA X-ray examination shows an assessment of improvement of left maxillary sinus disease, with a small amount of mucosal thickening persisting. Fee- basis examination performed at that time revealed the veteran's ears to be clear. His nose looked okay and his oropharynx and hypopharynx were clear. Allergy screening tests were positive. A VA outpatient record dated in February 2001 notes the veteran's complaint of sinusitis with congestion and pain. The impression was sinusitis for which medication was prescribed. The veteran was examined on a fee-basis in February 2001. VA diagnostic testing completed in February 2001 was interpreted as showing improvement of the left maxillary sinus disease, with a small amount of mucosal thickening persisting. The fee-basis examiner noted a history of sinus surgery in 1992. The veteran complained of post-nasal drip interfering with his ability to work and also reported he was constantly sick. The examiner reviewed prior computerized tomography scans and noted such showed minimal maxillary and right ethmoid sinusitis. The examiner also noted the veteran had chronic vasomotor rhinitis and nasal scarring, with mild chronic sinusitis. The examiner specifically opined that the veteran's sinus condition did not keep him from working. In April 2001, M. Rangitsch, M.D., reviewed medical records relevant to the veteran and also noted having examined the veteran in November 2000. Dr. Rangitsch noted that in November 2000 the impression had been that the veteran had a service-connected left foot problem and a traumatic left knee problem, the latter with fairly benign physical findings. Dr. Rangitsch opined that the veteran should not perform heavy work with his left foot but that a light-duty or sedentary-type activity should be feasible. X-rays showed mild degenerative changes in the foot. VA computerized tomography scanning completed in April 2001 showed minimal mucosal thickening in the maxillary sinuses and right ethmoid sinuses. In a rating decision dated in June 2001, the RO granted service connection for residuals of a left knee injury, evaluated as noncompensably disabling. In January 2002, C. Bash, M.D., an Associate Professor of Radiology and Nuclear Medicine, reviewed service medical records as well as post-service medical and lay evidence in the veteran's claims files and medical literature. Dr. Bash did not examine the veteran, stating that it was common for neuro-radiologists to make diagnostic and causation determinations based on information review. Dr. Bash concluded that the veteran's left knee and foot injuries resulted in pain and an abnormal gait in the left lower extremity that subsequently put abnormal stresses on the left hip and lumbar spine resulting in left hip and lumbar spine pathology. Dr. Bash cited to service medical evidence of left knee and heel injuries followed by persistent pain and required surgeries. Dr. Bash acknowledged Dr. Rangitsch's contrary opinion as to etiology, specifically the statement that, ...if somebody is not weight bearing on their foot, this would tend to decrease the amount of wear and tear on the left knee/hip area... indicating that such opinion ignored the fact that the veteran had had left knee pain and an altered abnormal gait since 1976. Dr. Bash also noted that Dr. Rangitsch did not cite to supporting literature, provide an alternative etiology, or have benefit of full review of relevant medical evidence. In July 2002, the veteran's attorney submitted a prescription history relevant to the veteran and argued that the veteran had been prescribed antibiotics for sinusitis infections on seven occasions in 2001. The attorney argued that such findings meet the criteria for a higher rating for sinusitis. The attorney also argued that the veteran's medications prevented him from working due to restrictions from driving or operating equipment while taking such medications. Analysis Service Connection In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in the active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent within one year from the date of termination of such service, such diseases shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such diseases during the period of service. 38 U.S.C.A. §§ 1101, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (2001). Service connection is also warranted for disability proximately due to or the result of a service-connected disability and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service- connected disability. In the case of aggravation, such secondary disorder is compensable only to the degree of disability over and above the degree of disability that would exist without such aggravation. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448, 449 (1995). Service connection may also be granted for a disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Left hip disability A review of the record since shortly after service discharge and continuing to date reveals the veteran's consistent complaint of left hip pain, which he has attributed to an altered gait caused by foot pain. Although the record includes one VA opinion dissociating such problems from the veteran's service-connected residuals of a left heel injury, significantly the file contains VA opinions suggesting a causal connection between the veteran's foot problems, an altered gait, and left knee problems. Service connection has been granted for the left knee and the veteran has been service-connected for his left heel problems for many years. Moreover, the VA opinions of record extend the causal relationship between an altered gait induced by heel problems to the veteran's currently manifested left hip pathology, diagnosed as persistent trochanter bursitis. Finally, based on a comprehensive file review, and consistent with the veteran's history, Dr. Bash directly related the veteran's hip pathology to the altered gait caused by his service- connected left heel and knee disabilities. As such, and any reasonable doubt being resolved in the veteran's favor, secondary service connection is warranted for left trochanter bursitis. Low back disability The veteran has also claimed long-term back pain caused by the altered gait induced by his heel pain. The Board acknowledges Dr. Bash's opinion relating current back pathology to the veteran's his service-connected left heel and knee disabilities. However, a review of the competent medical evidence of record, to include Dr. Bash's statement, is completely negative for any diagnosed back disability. The "pathology" referenced by Dr. Bash appears to be the veteran's account of back pain. The clinical and diagnostic medical evidence, to include the specific medical findings and diagnostic conclusions considered by Dr. Bash, reveals no note of any degenerative back changes shown by X-ray, lumbar strain, or even any motion limitation of the back. Rather, medical findings are limited to the veteran's own subjective account of back pain. The Court has considered claims of entitlement to service connection for disability manifested by pain, without additional pathology attributable to an identifiable and diagnosed condition, and has concluded that pain, in and of itself, does not constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). The Court of Appeals for the Federal Circuit (Federal Circuit) reviewed this question in Sanchez- Benitez v. Principi, 259 F. 3d 1356, 1361-62 (Fed. Cir., 2001). The Federal Circuit cited the statutory language relied on by the Court, noting that 38 U.S.C.A. §§ 1110, 1131 provide for compensation, "For disability resulting from personal injury suffered or disease contracted in the line of duty. . . ." The Federal Circuit considered the appellate arguments, but did not reach a determination on the question of whether pain alone can, where wholly unrelated to any current disability, may be a compensable disability. Thus, in this case, controlling law continues to provide that absent evidence of objective clinical low back pathology attributable to a diagnosis, there is no disability for which service connection may be granted. Pes cavus A review of the record shows two mentions of pes cavus. One is an X-ray finding, incidental to examination performed in October 1990. At that time no etiological opinion was offered relevant to pes cavus. Then, in November 2000, Dr. Rangitsch noted the veteran carried such a historical diagnosis. However, consistent with multiple examination reports, outpatient records, and other evaluation entries shown in the interim decade, Dr. Rangitsch's final diagnosis was a neuroma of the heel, without diagnosis of pes cavus attributable to the veteran's period of service or to his service-connected left heel disability. Similarly, Dr. Bash, after having considered the veteran's history of injury to the left foot in service, with subsequent complaints and findings, to include the one X-ray finding of pes cavus, diagnosed a neuroma. Another diagnosis shown in the record pertinent to the foot is plantar fasciitis, which is included in his award of service connection. There is, however, no competent evidence of currently existing pes cavus of the left foot that may be attributed to service or to service- connected disability. With respect to both the low back and pes cavus claims discussed herein above, the Board concludes by noting that as the record does not reflect that the veteran possesses a recognized degree of medical knowledge, his own opinions on medical diagnoses or causation are not competent to establish current diagnoses of any low back disability or of pes cavus, or to relate such to service or service-connected disability. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Rating Evaluations In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2001), and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the veteran's service-connected disabilities. The Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of the remote clinical histories and findings pertaining to such disabilities beyond that set out in brief herein above. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Schedule). The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2001). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2001). Sinusitis During the pendency of this appeal, the provisions of 38 C.F.R. § 4.97, concerning the evaluation of diseases of the nose and throat, were revised, effective October 7, 1996. See 61 Fed. Reg. 46,720 (1996). Where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Dudnick v. Brown, 10 Vet. App. 79 (1997); Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C.A. § 5110(g) (West 1991), can be no earlier than the effective date of that change. The Board must apply only the earlier version of the regulation for the period prior to the effective date of the change. VAOPGCPREC 3- 2000, published at 65 Fed. Reg. 33,421 (April 10, 2000). Prior to October 7, 1996, Diagnostic Code 6513 provides for assignment of a noncompensable rating for sinsusitis based on X-ray manifestations only, and where the symptoms are mild or occasional. A 10 percent evaluation is assigned where there was moderate symptomatology with discharge or crusting or scabbing, infrequent headaches. In order to warrant an assignment of a 30 percent evaluation, the claimant would have to show severe symptomatology with frequently incapacitating recurrences, severe and frequent headaches with purulent discharge or crusting reflecting purulence. A 50 percent rating is assigned for post-operative sinusitis, following radical operation, with chronic osteomyelitis requiring repeated curettage or severe symptoms after repeated operations. 38 C.F.R. § 4.97, Diagnostic Code 6513 (1996). Under the applicable criteria in effect from October 7, 1996, an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. A 10 percent evaluation is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non- incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting occurs. A 30 percent evaluation is warranted if there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment or; more than six non-capacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Assignment of a 50 percent evaluation is warranted on a showing of symptomatology following radical surgery with chronic osteomyelitis or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, Diagnostic Code 6513. January 17, 1978, to March 19, 1992 Here the Board first emphasizes that for each period considered herein below, statements offered by the veteran and several lay witnesses as to constant nasal drainage and the presence of other symptoms are competent only to establish that such symptoms were evident. Lay statements are not sufficient, however, to attribute manifestations to any diagnosis or to establish the overall severity of the sinusitis disability. Such is a medical determination. Furthermore, although the veteran's spouse reportedly has some medical training, she is not a physician or recognized as a nurse and did not participate in the evaluation or treatment of the veteran's symptoms. See cf. Goss v. Brown, 9 Vet. App. 109, 113 (1996) (treating nurse's statement enough to well ground claim where nurse participated in the treatment of the veteran for symptoms of frostbite). For the period January 17, 1978, to March 19, 1992, only the old rating criteria are for application. The competent medical evidence reflects that the veteran received treatment several times a year in the 1980s for complaints to include nasal discharge. Such medical notations are consistent with Dr. Rajapakse's April 1991 assessment that the veteran had been prescribed antibiotics for respiratory infections approximately every three-to-six months since 1981. Notably, the post-service report of VA examination and other X-ray evaluations prior to May 1992 do not demonstrate X-ray evidence of sinus abnormalities. The records of treatment do include some findings of nasal discharge, but in large part do not even specifically attribute such to sinusitis, instead noting upper respiratory infections or colds. In any case, such findings, even if clearly attributable to sinusitis, are consistent only with mild and infrequent symptoms, and thus do not meet the criteria for a compensable evaluation. The Board has considered arguments put forth by the veteran, in hearings and in personal statements, to the effect that his sinusitis has been characterized by severe and frequently recurrent episodes often requiring antibiotic treatment since service. Such arguments are not born out by the competent medical documentation, to include the medical summary provided by his private physician. Insofar as the competent evidence of record does not show more than mild and occasional sinus symptomatology, a compensable evaluation is not warranted during the period from January 17, 1978, to March 19, 1992. May 5 to September 8, 1992, and December 1, 1992, to October 6, 1996 Again, for the period May to September 1992, and from December 1992 to October 7, 1996, only the old rating criteria apply. During this time period a 10 percent rating was in effect for sinusitis. Again, although the veteran reports frequent episodes of sinusitis requiring medical intervention, the evidence of record does not show severe symptoms. There is no evidence of frequent incapacitating recurrences. Dr. Rajapakse himself indicates treatment only approximately every three-to-six months. The other medical evidence of record is consistent in showing the veteran to have received antibiotic treatment approximately two-to-four times per year for episodes of symptoms such as nasal drainage, sometimes diagnosed as sinusitis. The veteran is shown to have had good response to the antibiotic treatment and such treatment is not shown to be prolonged beyond a week or two. Also, although the veteran complained of headaches, which were eased with antibiotics, no medical professional noted severe and frequent headaches or other symptoms of sinusitis characterized as severe. Nor is there examination or clinical progress note evidence documenting frequent purulent discharge, signs of crusting or frequent bouts of sinusitis deemed severe in nature. Both clinical notations and interpretations of diagnostic testing instead predominantly characterize the veteran's sinus changes as mild, or, at most moderate. Such findings are insufficient to warrant a 30 percent rating under Diagnostic Code 6513 as extant prior to October 7, 1996. Beginning October 7, 1996 For the period after October 7, 1996, both the old and revised criteria may be applied. Again, however, despite the veteran's complaints, the evidence dated subsequent to October 1996 shows no more than two-to-four episodes of antibiotic treatment for sinusitis within a year. The February 2001 examination report noted only minimal sinusitis. Such findings are consistent with assignment of no more than a 10 percent rating under the old and the new criteria. The Board recognizes argument put forth by the veteran and his attorney to the effect that constant symptoms are manifested and require more antibiotic treatment than shown. In this regard the Board acknowledges that the veteran has been shown to use nasal sprays for nonservice-connected rhinitis, and also requires multiple medications unrelated to his sinusitis. The medical evidence does not show, however, that the veteran has required antibiotic treatment lasting four-to-six weeks three or more times per year, and does not support that he has had more than six episodes of non- incapacitating episodes per year. Nor does the evidence show severe symptomatology with frequently incapacitating recurrences, severe and frequent headaches with purulent discharge or crusting. The Board emphasizes that despite the veteran's account of his sinusitis being incapacitating, there is no objective evidence that he is frequently unable to function due to his sinusitis. Moreover, the most contemporary evidence shows his sinuses to be clear, with a diagnostic suggestion of improved and only minimal thickening of the sinuses still evident. Such findings are not indicative of severe sinusitis. Absent competent evidence of sinusitis episodes of increased severity and/or frequency, a higher rating is not warranted. 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, that doctrine is not applicable in the instant appeal and ratings in excess of noncompensable and 10 percent, for the respective periods cited above, are not warranted. 38 U.S.C.A. § 5107(b). Entitlement to an evaluation in excess of 10 percent for callosities of the plantar surface of the left heel for the period beginning June 6, 1989 The veteran is service-connected for callosities of the plantar surface of the left heel, with plantar fasciitis, evaluated as 10 percent disabling under Diagnostic Code 5310- 5284. 38 C.F.R. § 4.27 (2001) provides that hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. Foot injuries may be evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5284, which provides that a 10 percent evaluation is warranted if the disability is moderate, a 20 percent evaluation is warranted if the disability is moderately severe and a 30 percent evaluation is warranted if the disability is severe. 38 C.F.R. § 4.73, Diagnostic Code 5310 sets out the criteria for evaluating injuries to the intrinsic muscles of the foot, Muscle Group X; evaluations are based on injury to the plantar or dorsal portion of the foot. A noncompensable evaluation is assigned when there is evidence of slight disability of the dorsal portion of the foot, a 10 percent evaluation is assigned for both a moderate disability and moderately severe disability, and a 20 percent evaluation is assigned when there is evidence of severe disability in the dorsal portion of the foot. At the time of examination in November 2000, the veteran demonstrated a full range of foot and ankle motion, without deformity, and also evidenced full motor strength, sensation and deep tendon reflexes. The physician noted symptoms of pain, causing difficulty weight bearing and thus resulting in a change of gait. Notably, the physician also indicated the veteran's complaints of pain were out of proportion to the examination. Degenerative changes in the foot were described only as mild. Such findings are consistent with prior examination findings and are indicative of no more than mild impairment. Whether evaluated under Diagnostic Code 5284 or 5310, such level of impairment warrants no more than a 10 percent evaluation. The Board has also considered 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2001) as pertain to arthritis; however, an evaluation in excess of 10 percent is not warranted for arthritis of the foot unless there is sufficient resulting limitation of motion to warrant a higher rating under another diagnostic code. The Board notes the veteran's own complaints of severe pain, resulting in a severe limitation of his ability to utilize his foot, such as in ambulation. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The veteran has argued that he can only achieve full foot motion due to the use of his pain medications. Nevertheless, he is shown to maintain a full range of left foot motion throughout the appeal period. Also, both X-rays and clinical assessments are of mild disability due to the left heel injury and attempted surgical correction. As noted above, the most recent examiner indicated the veteran's own complaint of pain is not in proportion to actual clinical examination findings. Thus, his own assertions of severe pain and severe overall foot impairment are not probative and there is no competent evidence of limitation of motion of the foot or ankle warranting assignment of a higher rating pursuant to motion codes under 38 C.F.R. § 4.71a. The Board has also considered application of additional diagnostic codes. However, again, the medical evidence speaks only to mild disability attributable to residuals of a left heel injury, and manifesting in the form of plantar and heel pain causing an altered gait. Such symptoms are contemplated under the assigned percentage rating based on overall foot impairment. In particular the Board notes that the veteran cites to a neuroma at the scar site of his left heel as productive of pain and an impaired sensation. The competent evidence, however, is not indicative of neuritis, neuralgia or any nerve paralysis in the foot so as to warrant application of 38 C.F.R. §§ 4.123, 4.124, 4.124a (2001). Moreover, the Board notes that 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. 38 C.F.R. § 4.14 (2001). Thus, insofar as the veteran's symptom, whether considered based on plantar fasciitis or a neuroma, consists of pain, a subjective complaint of sensory disturbance and gait alterations, without additional, distinct symptom manifestation. As such, the assignment of several ratings under various diagnostic codes is not warranted in this case. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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, that doctrine is not applicable. 38 U.S.C. § 5107(b). Extra-schedular The Board has considered whether the case should be referred to the Director of the Compensation and Pension Services for extra-schedular consideration relevant to the veteran's sinusitis and left heel disabilities. An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1) (2001). The veteran has indicated that he has missed time from work due to both his heel and his sinusitis. The record also notes instances of required surgery and hospitalization for his sinusitis. However, the percentage ratings under the Schedule are themselves representative of the average impairment in earning capacity resulting from diseases and injuries. 38 C.F.R. § 4.1 (1997) specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Thus, factors such as missing time from work or requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the schedular evaluations assigned to the veteran's left heel disability and sinusitis. What the veteran has not shown in this case is the existence of unusual manifestations of the disabilities. Moreover, the medical evidence shows that the manifestations of sinusitis and left heel disability are symptoms contemplated by the schedular criteria. In sum there is no indication in the record that the average industrial impairment from either the veteran's left heel disability or from sinusitis would be in excess of that contemplated by the assigned evaluation. Therefore, the Board has determined that referral of this case for extra- schedular consideration is not in order. Entitlement to an extension of a temporary total disability rating based on the need for convalescence for sinusitis beyond November 30, 1992 A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a)(1), (2) or (3), set forth below, effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. (a) Total ratings will be assigned under this section if treatment of a service- connected disability resulted in: (1) Surgery necessitating at least one month of convalescence (2) Surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited) (3) Immobilization by cast, without surgery, of one major joint or more. (b) A total rating under this section will require full justification on the rating sheet and may be extended as follows: (1) Extensions of 1, 2 or 3 months beyond the initial 3 months may be made under paragraph (a)(1), (2) or (3) of this section. (2) Extensions of 1 or more months up to 6 months beyond the initial 6 months may be made under paragraph (a)(2) or (3) of this section upon approval of the Adjudication Officer. 38 C.F.R. § 4.30. The Court has held that notations in the medical record as to the veteran's incapacity to work after surgery must be taken into account in the evaluation of a claim brought under the provisions of 38 C.F.R. § 4.30. Seals v. Brown, 8 Vet. App. 291, 296-297 (1995); Felden v. West, 11 Vet. App. 427, 430 (1998). Furthermore, the Court has noted that the term "convalescence" does not necessarily entail in-home recovery. In this case a 100 percent rating for convalescence was assigned based on the veteran's September and October 1992 sinus surgeries. That rating ended November 30, 1992. The medical records pertaining to the surgeries show that up to the time the veteran was discharged in late October 1992 he improved, particularly after the second surgery. No further hospitalization was stated to be required and no particular convalescence period was identified by the competent medical professionals. Although the veteran was advised to report for follow-up after his discharge in October 1992, there is no medical documentation that such follow-up treatment occurred. Nor is there documentation of any further surgery or necessary medical management of sinusitis by VA or private physicians after November 30, 1992, and up to in or around 1993. The Board finds no credence to the veteran's assertion that he was denied VA treatment for his sinuses during such time period. The record is replete with evidence of the veteran's frequent use of VA facilities to receive appropriate treatment and evaluation. Here, the medical evidence simply shows no treatment visits pertinent to sinusitis for the months following the September and October 1992 surgeries. Moreover, the veteran's own statements as to whether he was able to return to work are inconsistent. In certain general statements he has indicated he was unable to work for over a year after his sinus surgery, yet in other statements he indicates ongoing employment or self-employment during that period. There is, in short, no credible evidence that the veteran required convalescence, delayed returning to work, or remained confined to his house or bed beyond November 30, 1992. As the preponderance of the evidence establishes that the veteran does not meet the criteria under 38 C.F.R. § 4.30(a)(1), (2) or (3), extension of the temporary total rating based on convalesence is not warranted. ORDER Entitlement to service connection for left hip disability, diagnosed as trochanter bursitis, is granted. Entitlement to service connection for low back disability is denied. Entitlement to service connection for pes cavus of the left foot is denied. Entitlement to a compensable evaluation for sinusitis for the period January 17, 1978, to March 19, 1992, is denied. Entitlement to an evaluation in excess of 10 percent for sinusitis for the period May 5 to September 8, 1992, and for the period beginning December 1, 1992, is denied. Entitlement to an extension of a temporary total disability rating based on the need for convalescence for sinusitis beyond November 30, 1992, is denied. Entitlement to an evaluation in excess of 10 percent for callosities of the plantar surface of the left heel for the period beginning June 6, 1989, is denied. REMAND In a decision dated in June 2001, the RO granted service connection and assigned an initial noncompensable evaluation for residuals of a left knee injury, effective August 23, 1990. The RO also denied entitlement to a total rating based on individual unemployability due to service- connected disability (TDIU) pursuant to 38 C.F.R. § 4.16 (2001). Through his attorney, the veteran has timely expressed disagreement with the effective date and percentage rating assigned to his left knee disability and with respect to the denial of TDIU. In the June 2001 decision, the RO also denied service connection for sepsis, claimed as related to service-connected sinusitis, and the RO denied entitlement to an increased rating for hemorrhoids. The veteran has expressed disagreement with the denial of benefits based on sepsis and the denial of an increased rating for hemorrhoids. In a decision dated in November 2001, the RO granted service connection for major depression and assigned a 30 percent evaluation, effective January 4, 1999. The RO also denied service connection for a gastrointestinal disorder. In correspondence dated in January 2002, the veteran indicated his disagreement with the 30 percent rating assigned for major depression and the denial of service connection for a gastrointestinal disorder. The RO has not yet issued a statement of the case in response to the above-cited notices of disagreement. When there has been an initial RO adjudication of a claim and a notice of disagreement as to its denial, the claimant is entitled to a statement of the case, and the RO's failure to issue a statement of the case is a procedural defect requiring remand. Manlincon v. West, 12 Vet. App. 238 (1999); Godfrey v. Brown, 7 Vet. App. 398, 408-410 (1995). Moreover, the Board notes that the decision herein contains a grant of service connection for a left hip disability. In effectuating the service connection grant, the RO will assign an appropriate effective date and percentage rating. Such action may impact the veteran's rating assignment for the period January 17, 1978, to June 6, 1989. As such, his claim of entitlement to a compensable evaluation based on multiple, noncompensable service-connected disabilities under 38 C.F.R. § 3.324, for that period is deferred. Accordingly, the case is REMANDED to the RO for the following: 1. The RO must issue a statement of the case, containing all applicable laws and regulations, on the issues of entitlement to an earlier effective date for the grant of service connection for residuals of a left knee injury; entitlement to an initial compensable evaluation for residuals of a left knee injury; entitlement to TDIU; entitlement to an evaluation in excess of 30 percent for major depression; entitlement to an increased rating for hemorrhoids, entitlement to service connection for a gastrointestinal disability; and entitlement to service connection for sepsis. The veteran should be advised of the requirements to perfect his appeal. 2. The RO should review the claims files and take appropriate action with respect to the assignment of an appropriate effective date and rating for the grant of service connection for a left hip disability. Thereafter, to the extent the matter is not rendered moot by the new awards of service connection, the RO should again consider the veteran's claim of entitlement to a compensable evaluation based on multiple, noncompensable service-connected disabilities under 38 C.F.R. § 3.324. If the benefit sought on appeal is not granted to the veteran's satisfaction, the veteran and his attorney should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. No action is required on the part of the veteran or his representative until further notice is received. By this action, the Board intimates no opinion, legal or factual, as to any ultimate disposition warranted in this case. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 2002) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. Shane A. Durkin Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.