Citation Nr: 0807786 Decision Date: 03/06/08 Archive Date: 03/17/08 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 gastrointestinal disability as secondary to a service-connected left heel disability. 2. Entitlement to service connection for sepsis as secondary to service-connected sinusitis. 3. Entitlement to an initial rating in excess of 30 percent for major depressive disorder. 4. Entitlement to an initial compensable evaluation for residuals of a left knee injury prior to September 2, 2006, and an initial rating higher than 10 percent from September 2, 2006, to the present. 5. Entitlement to an initial rating in excess of 10 percent for left trochanter bursitis prior to September 2, 2006, and an initial rating higher than 20 percent from September 2, 2006, to the present. 6. Entitlement to a compensable evaluation for multiple, noncompensable service-connected disabilities under the provisions of 38 C.F.R. § 3.324 for the period from January 17, 1978, to June 6, 1989. 7. Entitlement to service connection for pes cavus of the left foot. 8. 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. 9. Entitlement to a total disability rating based on unemployability due to service-connected disabilities (TDIU). [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 A. Kendall, Attorney WITNESS AT HEARINGS ON APPEAL The veteran ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The veteran served on active duty from September 1974 to January 1978. This case comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cheyenne, Wyoming. The veteran appeared before the undersigned Veterans Law Judge and presented personal testimony at a Travel Board hearing in July 1999. The Board notes that each of these matters has previously been the subject of a Board decision. In a September 2002 decision (Volume 4 of the claims files), the Board denied service connection for the claimed pes cavus, and 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. The veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a Memorandum Decision dated in April 2006, the Court vacated that portion of the Board's September 2002 decision which denied the two issues listed on the first page above, and remanded them to the Board for development consistent with the Court's decision. The Court affirmed the Board's decision with respect to all other appealed issues. In May 2004 (Volume 5 of the claims files), the Board remanded the issues of entitlement to service connection for gastrointestinal disability and sepsis, entitlement to increased initial ratings for major depressive disorder, residuals of left knee injury, and left trochanter bursitis, as well as entitlement to a compensable evaluation for multiple, noncompensable service-connected disabilities and entitlement to a TDIU, for additional evidentiary development. Those matters have since been returned to the Board for further appellate action. The issues of entitlement to service connection for pes cavus of the left foot, 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, and entitlement to TDIU, are addressed in the REMAND that follows the order section of this decision. FINDINGS OF FACT 1. A gastrointestinal disability is not etiologically related to medication taken for the service-connected left heel disability. 2. The veteran does not have a current diagnosis of sepsis or chronic residuals thereof. 3. The veteran's major depressive disorder is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. Since September 2, 2006, the veteran's left knee disability has been manifested by X-ray evidence of arthritis and pain on motion; extension is full and flexion is not limited to less than 45 degrees. 5. Prior to September 2, 2006, the veteran's left knee disability was productive of no significant functional impairment. 6. Since September 2, 2006, the veteran's left trochanter bursitis is manifested by hip flexion measured to 90 degrees, and hip abduction measured to 30 degrees. 7. Prior to September 2, 2006, the veteran's left hip disability was manifested by hip flexion measured to 65 degrees before onset of pain. 8. Prior to June 6, 1989, the veteran did not have two or more separate, permanent service connected disabilities of such character as to clearly interfered with normal employability. CONCLUSIONS OF LAW 1. A gastrointestinal disability is not proximately due to or the result of the veteran's service-connected left heel disability. 38 C.F.R. § 3.310 (2007). 2. Sepsis, or chronic residuals thereof, is not proximately due to or the result of the veteran's service-connected sinusitis. 38 C.F.R. § 3.310 (2007). 3. The criteria for a disability rating higher than 30 percent for major depressive disorder have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9434 (2007). 4. Since September 2, 2006, the criteria for a disability rating higher than 10 percent for a left knee disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5003, 5010, 5257-5261 (2007). 5. Prior to September 2, 2006, the criteria for a compensable disability rating for a left knee disability were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.31, 4.71a, Diagnostic Code 5003, 5010, 5257-5261 (2007). 6. Since September 2, 2006, the criteria for a disability rating higher than 20 percent for a left hip disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5253 (2007). 7. Prior to September 2, 2006, the criteria for a disability rating higher than 10 percent for a left hip disability were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5253 (2007). 8. The criteria for a 10 percent rating for multiple, noncompensable service-connected disabilities prior to June 6, 1989, are not met. 38 C.F.R. § 3.324 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran is seeking service connection for a gastrointestinal disability and for sepsis residuals. He is also seeking higher disability ratings for his service- connected major depressive disorder, left knee disability and left hip disability. In addition, he is seeking a compensable evaluation for multiple, noncompensable service- connected disabilities under the provisions of 38 C.F.R. § 3.324 for the period from January 17, 1978, to June 6, 1989. The Board will initially discuss certain preliminary matters, and will then address the pertinent law and regulations and their application to the facts and evidence. The Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2007), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2007), 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. In addition, VA must also request that the veteran provide any evidence in the claimant's possession that pertains to the claim. The Board also notes that the Court has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Court further held that VA failed to demonstrate that, "lack of such a pre-AOJ-decision notice was not prejudicial to the appellant, see 38 U.S.C. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that "[i]n making the determinations under [section 7261(a)], the Court shall . . . take due account of the rule of prejudicial error")." Id. at 121. However, the Court also stated that the ;,failure to provide such notice in connection with adjudications prior to the enactment of the VCAA was not error and that in such cases, the claimant is entitled to "VCAA-content complying notice and proper subsequent VA process." Id. at 120. The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the case at hand, the veteran's sepsis, gastrointestinal, psychiatric, knee, and hip claims were initially received before the enactment of the VCAA in November 2000. The record reflects that, with respect to the claims decided here, the originating agency provided the veteran with the notice required under the VCAA by letter mailed in March 2001. The veteran responded in May 2001 that all necessary information was on file with VA. Although the originating agency did not specifically request the veteran to submit all pertinent evidence in his possession, it did inform him of the evidence that would be pertinent and request him to submit such evidence or provide VA with the information and any authorization necessary for VA to obtain the evidence on his behalf. Therefore, the Board believes that the veteran was on notice of the fact that he should submit any pertinent evidence in his possession. A subsequent letter, pertaining to the claimed gastrointestinal disorder was sent in October 2006, which did contain this instruction. Although the veteran was not been provided notice of the type of evidence necessary to establish disability ratings or effective dates for service connection claims until March 2006, after initial adjudication, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). As explained below, the Board has determined that service connection is not warranted for the veteran's sepsis and gastrointestinal disorder. Consequently, no disability rating or effective date will be assigned, so the failure to provide earlier notice with respect to those elements of the claims was no more than harmless error. Following the provision of the required notice and the completion of all indicated development of the record, the RO readjudicated the veteran's service connection claims in January 2007. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had VCAA notice been provided at an earlier time. The Court has recently provided guidance with respect to the notice that is necessary in increased rating claims. See Vazquez-Flores v. Peake, No. 05-0355 (U.S. Vet. App. January 30, 2008). However, that case dealt with claims "that an already service connected disability has worsened or increased in severity." Here, with respect to the initial rating for major depressive disorder, and left hip and knee disabilities, the veteran is challenging the initial evaluation and effective date assigned following the grant of service connection. Accordingly, that decision is not applicable to the rating claims decided herein. The Board also notes that the veteran has been afforded appropriate VA examinations and service medical records and pertinent VA medical records have been obtained. The Board remanded the psychiatric, gastrointestinal, sepsis, knee and hip claims in May 2004 so that updated VA medical records could be obtained, and so that current VA examinations could be conducted with respect to some of the claims. In response, the RO obtained updated VA medical records and scheduled the veteran for VA examinations, which were conducted in late 2006. Neither the veteran nor his attorney has identified any outstanding evidence, to include medical records, that could be obtained to substantiate any of these claims. The Board is also unaware of any such outstanding evidence. In the August 2006 psychiatric examination report, the veteran indicated that he had applied for Social Security Disability benefits but was not eligible for those benefits because of lack of work credits. There is no indication from the veteran's statements that there exists any additional evidence resulting from the veteran's application that has not already been obtained. The Board notes that the report of a September 2006 VA sinus examination includes notation of some records which could not be located by the examiner, but which were identified by the veteran during the interview. These include a discharge summary from a January 1998 hospitalization. The examiner stated that he checked VA's electronic records and that the discharge summary had been purged on January 6, 1999. The veteran also referred to a Dr. Gotti, from whom the veteran obtained antibiotic prescriptions for his sinusitis. With respect to the discharge summary, all indications are that this record has been destroyed, and there is no reasonable possibility that an additional remand would aid the Board's inquiry, but would rather serve only to unnecessarily delay a decision. See Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). With respect to the records of Dr Gotti, the Board notes that the issue to be resolved is whether the veteran has a current disability related to sepsis. By the veteran's account, Dr. Gotti treated him for sinusitis, and he last saw Dr. Gotti 2 years prior to the September 2006 examination. Given the conclusion of the September 2006 examiner that the veteran had no current residual disability from sepsis, the Board concludes that further development to obtain treatment records dated prior to the September 2006 examination could not conceivably aid in the Board's determination as to whether the veteran has a current disability. In sum, the Board is satisfied that the RO properly processed these claims following the provision of the required notice and that any procedural errors in its development and consideration of the claims were insignificant and non prejudicial to the veteran. . Accordingly, the Board will address the merits of the claims. Legal Criteria Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2007). Direct service connection may not be granted without medical evidence of a current disability, medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may be granted for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection on a secondary basis may not be granted without medical evidence of a current disability and medical evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512-514 (1998). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Higher Initial Ratings Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2007). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2007). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2007). In every instance where the minimum schedular evaluation requires residuals and the schedule does not provide for a zero percent evaluation, a zero percent evaluation will be assigned when the required symptomatology is not shown. 38 C.F.R. § 4.31 (2007). The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2007) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2006). See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to this regulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 state that when evaluating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2007). Multiple Noncompensable Evaluations Whenever a veteran has two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. Analysis Service Connection It is the veteran's essential contention for purposes of this appeal that he incurred a gastrointestinal disability as a result of taking pain medication for his service-connected left heel disability. He also contends that he has sepsis, or chronic residuals thereof, as a result of his service- connected sinusitis. As an initial matter, the Board observes that the Board adjudicated the issue of entitlement to service connection for a gastrointestinal disability on a direct basis in June 1995. The veteran is not seeking to reopen that claim, but now seeks entitlement to service connection on a secondary basis only. The RO limited its adjudication of the issue to secondary service connection. The veteran does not contend, nor does the record on appeal demonstrate, that the claimed sepsis had its onset during his period of military service. The Board's discussion will accordingly focus on the veteran's claims of entitlement to service connection on a secondary basis. As set out above, in order to prevail on the issue of entitlement to secondary service connection, there must be evidence of a current disability that is medically related to a service-connected disability. Service connection is currently in effect for a left heel disability and for sinusitis. However, a review of the claims files does not reveal a current diagnosis of sepsis or any chronic residuals thereof. The veteran was hospitalized in January 1998 with shaking, chills, and a high fever. The admission examination notes that the veteran "may have an --- syndrome, but will not rule out the possibility of septicemia." A bacterial sepsis resulting from the veteran's sinusitis was noted as "a possibility." The veteran was afforded a VA examination in September 2006 to determine whether a diagnosis of sepsis was currently supported, or whether there were current residuals of sepsis. The examiner reviewed the claims files, including the record of a January 1998 hospital admission examination, and concluded that the medical evidence of record did not support a diagnosis of sepsis, septicemia, or any residual disability. It is now well-settled that in order to be considered for service connection, a claimant must have a current disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection may not be granted unless a current disability exists]. A "current disability" means a disability shown by competent medical evidence to exist at the time of the award of service connection. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Chelte v. Brown, 10 Vet. App. 268 (1997). Symptoms alone, without a finding of an underlying disorder, cannot be service-connected. Moreover, a diagnosis by history only is not a current disability. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The Board acknowledges the veteran's belief that he has residual disability from sepsis. However, while the veteran is competent to report his symptoms, as a lay person without medical training, he is not competent to render a diagnosis. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). The Board therefore finds that in the absence of an identified disability of sepsis or chronic residuals thereof, service connection is not in order. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). With respect to the gastrointestinal claim, diagnosed as diverticulosis, the question which remains to be answered by the Board is whether this current disability is proximately due to, or the result of, the veteran's service-connected left heel disability and the medication taken therefor. The veteran was afforded a VA examination in July 2001, and the examiner stated his opinion that there was no relationship between the medication taken for heel pain and the veteran's diverticulosis. There is no medical opinion of record that conflicts with this opinion. The Board acknowledges the veteran's belief that his diverticulosis is related to the medication taken for heel pain. However, while the veteran is competent to report his symptoms, as a lay person without medical training, he is not competent to relate his symptoms to a particular etiology. Espiritu, 2 Vet. App. at 494-5. Accordingly, the Board concludes that the preponderance of the evidence is against this claim. Initial Ratings (i.) Major Depressive Disorder Service connection for depressive disorder was granted in a November 2001 rating decision, with the assignment of a 30 percent rating, effective from January 4, 1999. The veteran appealed the disability rating assigned in that decision. In May 2004, the claim was remanded to obtain additional VA treatment records and a current VA examination. Under the applicable rating schedule, a 30 percent rating represents occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). The next higher 50 percent rating is available where the evidence establishes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In this case, the evidence does not reflect the type or degree of symptomatology, or its effects, contemplated for a rating in excess of 30 percent. The evidence is not consistent with a flattened affect. The August 2006 VA examiner specifically found that the veteran's affect was not flat, and that he did not have a depressed continence or demeanor. The July 2001 VA examiner found the veteran's mood to be only mildly constricted, but not flattened. On examination in January 1999, the veteran's affect was bright, almost euphoric. In progress notes dated in July 2003, November 2003, August 2004 and March 2005, the veteran's affect was noted as congruent to mood, which was variously described as upbeat or less depressed. The evidence is not consistent with panic attacks more than once a week. Indeed, no panic attacks have been described. The evidence is not consistent with impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks). The August 2006 VA examiner found that the veteran's memory appeared to be intact for distant and recent events. According to the July 2001 VA examiner, the veteran's recent and remote memory was generally intact, although he had some fogginess secondary to his medications. In January 1999, the veteran's memory and orientation appeared to be good. In July 2003, November 2003, August 2004, and March 2005, the veteran was found to be an appropriate historian, and his memory was intact. The evidence is not consistent with impaired judgment or difficulty in understanding complex commands. The August 2006 VA examiner found that the veteran's judgment appeared to be at least fair to good. In January 1999, there was no evidence of bizarre or delusional thinking such as hallucinations, delusions, or paranoid thoughts. The veteran was found to have what appeared to be fairly good insight and judgment. The veteran was also noted to have good insight and judgment in October 2005 and March 2005. In a November 2003 progress note the veteran's thought process was found to be logical. The evidence is not consistent with impaired abstract thinking. The August 2006 VA examiner found that the veteran was able to engage in abstract conceptualization because he provided a suitable interpretation of a proverb. He also found that there was no indication of formal thought disorder in the veteran's speech or by observation. There was no impairment of thought processes or communication, there were no inappropriate behaviors noted or reported. The evidence is not consistent with disturbances of motivation and mood. The August 2006 VA examiner found that the veteran's mood was stable and within normal limits. He also found that the veteran did not appear to be significantly anxious, although he was moderately aroused and somewhat passionate about his desire to win benefits. The July 2001 VA examiner found that the veteran's mood was only mildly depressed. The evidence is not consistent with difficulty in establishing effective work and social relationships. The August 2006 VA examiner noted that the veteran indicated that he thought he would be able to attend work every day in spite of his depression. The examiner found that it was likely, however, that the veteran's depression would affect his efficiency and productivity at mild to moderate levels on a frequent basis, however, were he employed. The examiner formed the opinion that the veteran's depression did not render him unemployable, and that he would be able to maintain employment in many environments, but certainly in a sedentary work environment that was loosely supervised and involved little contact with the public. The examiner's opinion was that the veteran's major depressive disorder, while present at moderate levels, did not appear to be severe enough to render him unemployable or to prevent him from functioning in many employment settings. The veteran's social functioning was impaired at a mild to moderate level, as the veteran cited irritability as a problem, and also there appeared to be a lack of empathy and an inattention to grooming and hygiene. However, this was noted to be possibly secondary to personality characteristics as much as to manifestations of his depression. The Board notes that the veteran has been diagnosed with a narcissistic personality disorder, and service connection is prohibited for personality disorders. See 38 C.F.R. § 3.303, 4.9, 4.127 (2007). Moreover, the veteran's social interactions were described as lively and energetic. The Board acknowledges that the July 2001 VA examiner noted that the veteran feels withdrawn from his social activities; however, in March 2005, the veteran stated that he has been reasonably comfortable in his overall lifestyle. He felt that his family was very supportive of him. So long as he maintains his medications, he felt that his overall quality of life was as good as it could be. While the record does indicate some speech-related symptomatology, the Board concludes that the evidence is not consistent with circumstantial, circumlocutory, or stereotyped speech. The August 2006 VA examiner found that the veteran's speech was often tangential and verbose, and that he would not provide direct answers to the questions posed by the examiner and would provide lengthy tangential explanations that were only partially relevant. The veteran's pattern of speech indicated that he was largely self-absorbed and had great difficulty with taking a point of view of other persons. However, this does not appear to approximate the rating criteria. The Board notes that the examiner diagnosed a narcissistic personality disorder and thought some of his social impairment was attributable to this. Moreover, the August 2007 VA examiner found that the veteran's speech was logical and without loose associations, findings which would appear to be inconsistent with circumstantial or circumlocutory speech. In January 1999, the examiner noted some pressuring in the veteran's speech, but would not say that he had loose associations or full blown pressuring of speech, but only that, at times, he was difficult to interrupt. The examiner also noted that the veteran had good language skills. In October 2005, the veteran was noted to speak clearly and accurately and appropriately. In August 2004 and November 2003 progress notes, his speech pattern, quality, quantity and modulation were within normal limits and spontaneous. Overall, while the veteran has been noted to be verbose and somewhat indirect in his responses, it is the finding of the Board that this symptomatology does not approximate circumstantial, circumlocutory, or stereotyped speech. The Board acknowledges that the August 2006 examiner made findings pertinent to the criteria for ratings higher than 50 percent. For instance, the examiner found that the veteran's grooming and hygiene were poor, as it appeared that he had not washed his hair for a few days and there was a noticeable odor of perspiration. Among the criteria for a 70 percent rating is neglect of personal appearance and hygiene. However, the examiner also diagnosed a narcissistic personality disorder in addition to major depressive disorder. He found that the veteran's inattention to grooming and hygiene may have been secondary to personality characteristics as much as to manifestations of his depression. Also significant, the examiner found that, although the veteran had neglected his hygiene, he appeared to be able to maintain basic activities of daily living. In light of the examiner's overall findings of mild to moderate psychiatric impairment attributable to the veterans' service- connected disorder, and his assignment of a Global Assessment of Functioning score of 60, the Board assigns less probative weight to the findings with respect to personal hygiene. In August 2004 and March 2005, the veteran was found to be well dressed and well groomed. His self-care activity was described as intact. The veteran was found to be well dressed in January 2003, July 2003, and November 2003 progress notes. Self care activities were also described as intact. In addition to evidence pertaining to personal appearance and hygiene, the evidence also contains some findings with respect to suicidal ideation. This is also a criterion for the 70 percent level. However, the August 2006 examiner described the veteran's suicidal ideation as "transient." The examiner found that, although the veteran had recently thought about suicide, he denied that he had ever attempted suicide. Most significant in the Board's view, on objective examination, the veteran denied current suicidal or homicidal ideation. This is consistent with prior findings. On VA examination in July 2001, the veteran described past suicidal thoughts, but said he has not had further suicidal ideation. He denied current suicidal or homicidal ideation. Similarly, in January 1999, no suicidal ideation was in evidence. In July 2003, August 2004 and October 2005, the veteran did not voice any suicidal ideation or thoughts of self-harm or harm to others. In sum, while the veteran has reported to a medical examiner recent thoughts about suicide, it was the opinion of that examiner that this was a transient condition, and that the veteran did not demonstrate suicidal ideation objectively. While this criterion is inherently based on the veteran's statements, the Board assigns more probative weight to the examiner's objective conclusions based on those statements than to the statements themselves. In denying a 50 percent rating, the Board places great weight on the evaluations of the trained medical professionals who have interviewed the veteran. The GAF scores assigned by those medical professionals have ranged from 55 to 75. These GAF scores appear to be based on the veteran's reported symptomatology. GAF scores are based on a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. In addition to the GAF of 60 assigned in August 2006, which was found to be indicative of a person who is experiencing moderate symptoms and moderate difficulty in social and occupational functioning, a GAF score of 60 was also assigned in July 2001. Psychiatric progress notes in January 2003, March 2003, May 2003, July 2003, and November 2003 all contain GAF scores of 55. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Id. The Board notes that some higher GAF scores were also assigned. GAF scores of 65 were assigned in November 2003, August 2004, March 2005 and October 2005. A GAF score of 75 was assigned in January 1999. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). Id. The Board notes that GAF scores do not dictate any particular rating. However, the Board believes that the veteran's GAF scores are consistent with the objective findings, which show symptomatology that generally ranges from mild to moderate throughout the period on appeal. The Board further notes that words such as "mild" and "moderate" are not defined in the VA Schedule for Rating Disabilities [or in the DSM-IV]. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. § 4.6 (2007). It should also be noted that use of terminology such as "mild" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2007). In this case, while the Board finds that the examiners' descriptions of the severity of the veteran's depression are consistent with the objective symptomatology described, it is the objective symptomatology which the Board finds most probative. In sum, the preponderance of the evidence demonstrates that the impairment from the disability does not more nearly approximate the reduced reliability and productivity required for a higher rating than the occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks contemplated by the assigned rating. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999 (ii.) Left Knee The veteran's service-connected left knee disability has been assigned a 10 percent rating from September 2, 2006, to the present and a noncompensable rating prior to that date. Service connection was granted for a left knee disability in June 2001. Initially, a noncompensable rating was assigned. That rating was increased to 10 percent in January 2007, and the increase was made effective from September 2, 2006, the date of a VA examination showing an increase in disability. Accordingly, the Board must consider entitlement to increased initial ratings during both periods. The veteran's left knee disability is currently rated under Diagnostic Code 5010 (arthritis due to trauma). However, that code simply directs that Diagnostic Code 5003 (degenerative arthritis) should be used. Diagnostic Code 5003 provides that degenerative arthritis established by X- ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2007). Limitation of flexion of a leg warrants a noncompensable evaluation if flexion is limited to 60 degrees, a 10 percent evaluation if flexion is limited to 45 degrees, a 20 percent evaluation if flexion is limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of a leg warrants a noncompensable evaluation if extension is limited to 5 degrees, or a 10 percent evaluation if extension is limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In this case, the evidence prior to September 2006 does not show limitation of motion of the left knee to such a degree as would justify a compensable rating under the provisions of Diagnostic Code 5260 or 5261, nor does it objectively establish the presence of pain on motion or any limitation of motion. On VA examination in November 2000, the veteran was noted to have full range of motion of the left knee. Thus, although X-rays taken in November 2000 showed degenerative changes of the left knee, the criteria for a 10 percent rating under Diagnostic Code 5003 are not met. In a February 1998 progress note, range of motion was measured from 0 to 130 degrees. Normal knee motion is provided in the rating schedule as 0 to 140 degrees. See 38 C.F.R. § 4.71a, Plate II. While the veteran's range of motion is slightly less than normal, the regulation provides that limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The examiner noted that the knee was tender in the posterior portion, but did not describe any objective evidence of painful motion, nor was there any description of muscle spasms or swelling. The report of a September 2006 examination is the first evidence of record that provides such objective evidence. The Board also notes that X-rays in October 1990 were normal and did not show arthritis. Flexion of the left knee at that time was measured to 135 degrees. The Board notes that the veteran's statements are not considered objective evidence and do not satisfy the criteria for a compensable rating even when those statements are recited in medical reports. As an example, the veteran stated to the September 2006 VA examiner that his left knee was "always swollen." However, on objective examination, no swelling was found. Further, the January 2002 summary and opinion of Craig N. Bash, M.D. while certainly competent with respect to diagnosis and etiology, does not include the results of an examination of the veteran, and therefore does not provide objective evidence as required under the regulation. Moreover, although there is X-ray evidence of arthritis, involvement of more than one major joint or group of minor joints is required for a compensable evaluation based on X-ray evidence of arthritis. The veteran's left knee was originally rated under Diagnostic Code 5257. The veteran underwent an arthroscopy of the left knee in December 1991. A report indicated that the procedure was uneventful and revealed the presence of chondromalacia of the left medial femoral condyle. Given the nature of the knee injury as internal derangement of the knee, the Board has considered whether a compensable rating is warranted under Diagnostic Code 5257, a general provision for rating knee injuries on the basis of lateral instability and recurrent subluxation. However, in a February 1998 progress note, the knee was noted as stable. In a July 1991 progress note, varus and valgus stability were intact. There is no indication in the medical evidence prior to September 2006 of any lateral instability or subluxation. The Board has also considered Diagnostic Code 5259, which provides that removal of semilunar cartilage warrants a 10 percent evaluation if it is symptomatic. The record does not reflect that the veteran has undergone removal of semilunar cartilage. Accordingly, this Diagnostic Code is not applicable to the facts of this case. Based on the evidence pertaining to the status of the veteran's left knee disability prior to the September 2006 VA examination, the Board concludes that there is no basis to assign a compensable rating for the veteran's left knee disability during that period. While entitlement to a 10 percent rating is substantiated by the September 2006 VA examination report, the evidence from September 2, 2006, to the present does not show limitation of motion of flexion of the left knee to such a degree as would justify a 20 percent or higher rating. In addition, it does not show the presence of any limitation of extension. On VA examination in September 2006, range of motion was measured from 0 to 125 degrees, with pain experienced throughout the range. The Board notes that a 10 percent rating is currently supported on the basis of X-ray evidence of arthritis and pain experienced on motion, see De Luca. The Board notes however that, while there is X-ray evidence of arthritis, separate 10 percent ratings cannot be awarded under the provisions of Diagnostic Code 5003 and the DeLuca provisions. See Diagnostic Code 5003, Note (1), which provides that the 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Consideration has also been given to assigning a staged rating; however, at no time during the period in question has the disability warranted more than the currently assigned schedular ratings. See Hart, 21 Vet. App. 505; Fenderson, 12 Vet. App. 119. In sum, there is no schedular basis for assigning a compensable disability rating prior to September 2, 2006, or more than a 10 percent schedular rating on or after that date. (iii.) Left Hip The veteran's service-connected left hip disability has been assigned a 20 percent rating from September 2, 2006, to the present and a 10 percent rating prior to that date. Service connection was granted for a left hip disability in December 2002, based on a June 1989 claim. Initially, a 10 percent rating was assigned. That rating was increased to 20 percent in January 2007, and the increase was made effective from September 2, 2006. Accordingly, the Board must consider entitlement to increased initial ratings during both periods. The veteran's left hip disability has been rated under Diagnostic Code 5252 and 5253. Under Diagnostic Code 5252, a 10 percent rating is assigned where there is flexion limited to 45 degrees. A 20 percent rating requires flexion limited to 30 degrees, and a 30 percent rating requires flexion that is limited to 20 degrees. Under Diagnostic Code 5253, a 10 percent rating requires a showing that the veteran cannot toe-out more than 15 degrees or cannot cross his legs. A 20 percent rating requires a showing that motion is lost beyond 10 degrees of abduction. In this case, the evidence prior to September 2006 does not show limitation of motion of the left hip to such a degree as would justify a 20 percent rating. On VA examination in November 2000, the veteran was noted to have full range of motion of the left hip. A November 1992 progress note shows that the veteran could flex his hip to 90 degrees, abduction was to 30 degrees, internal rotation was to 25 degrees, and external rotation was to 10 degrees. Similar findings were reported in June and July 1992. An October 1990 progress note shows flexion to 120 degrees, extension to 5 degrees, abduction to 35 degrees, adduction to 30 degrees, external rotation to 35 degrees and internal rotation to neutral. Such measurements do not meet the criteria for a 20 percent rating under either diagnostic code. The evidence from September 2, 2006, to the present does not show limitation of motion of the left hip to such a degree as would justify a 30 percent or higher rating. The Board notes that under Diagnostic Code 5253, a 20 percent rating is the maximum rating available. Under Diagnostic Code 5252, a 30 percent rating requires flexion that is limited to 20 degrees. On VA examination in September 2006, hip flexion was measured to 65 degrees, with pain limiting further movement. This is interpreted as the point of onset of pain. Accordingly, the criteria for a 30 percent rating are clearly not met, even considering the De Luca provisions. The Board further notes in reference to De Luca, that no muscle atrophy was noted in the hip/buttock area, and strength assessment of the hip joint was normal. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher rating than those currently assigned. See Hart, 21 Vet. App. 505; Fenderson, 12 Vet. App. 119. In sum, there is no schedular basis to assign a disability rating in excess of 10 percent prior to September 2, 2006, or a disability rating in excess of 20 percent on and after that date. Other Considerations In addition, the Board has considered whether this case should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. The record reflects that the veteran has not required frequent hospitalizations for his major depressive disorder, knee disability, or hip disability and that the manifestations of these disabilities are not in excess of those contemplated by the schedular criteria. With respect to interference with employment, the August 2006 VA examiner's opinion was that the current severity of the veteran's major depressive disorder was moderate, and did not appear to be severe enough to render him to be unemployable or to prevent him from functioning in many employment settings. In a January 2007 addendum, the September 2006 VA general medical examiner provided his opinion that the knee and hip problems limit employment requiring prolonged standing, and that repetitive stooping or squatting would not be feasible. It was the examiner's opinion that it would not be feasible for the veteran to work as an electrician, as this requires stooping, squatting and other maneuvers not feasible due to his hip and knee disabilities. On the other hand, he believed that sedentary employment would be feasible. The Board notes that a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Further, the criteria for mental disorders specifically address occupational impairment. The Board finds that the disability ratings currently assigned for the hip, knee, and psychiatric disorders are consistent with the evidence. In sum, there is no indication in the record that the average industrial impairment from the service-connected disabilities would be in excess of that contemplated by the assigned evaluations. Accordingly, the Board has concluded that referral of this case for extra-schedular consideration is not in order. Entitlement Under 38 C.F.R. § 3.324 During the period on appeal, from January 17, 1978, to June 6, 1989, service connection was in effect for sinusitis and callosities of the plantar surface of the left heel, both of which were noncompensably disabling. The issue to be determined on appeal is whether those conditions were of such character as to clearly interfere with normal employability. In this case, the Board finds that they were not. Private records dated from 1984 through 1988 show occasional treatment for sinuses. On VA examination in November 1978, no abnormality of the sinuses was found. Although the veteran told the examiner that he was unable to walk properly due to his left heel, on objective evaluation, the veteran was described as ambulating with a normal alternating gait, and to be in no acute distress. No pain was produced on percussion over the plantar surface of the left heel. Based on the objective evidence, showing quite minimal symptomatology for both conditions, the Board can identify no clear interference with normal employability resulting from the noncompensable sinusitis and callosities of the left heel. The Board acknowledges that the veteran maintains that these disabilities did interfere with normal employability, and in so doing, he disagrees with the medical findings of record. In support of his claim, the veteran has argued that his occupation as a locksmith required him to walk and stand for long periods, and that this aggravated his left foot symptomatology, pain in particular. However, the Board finds that the experience of pain and other symptomatology on the job does not alone establish interference with normal employability; nor does ones unsuitability for a particular profession imply such interference. The Board finds it particularly significant that the veteran stated to VA and to medical examiners that he was unable to perform the duties of a locksmith, but in a letter from the veteran received in November 1995, he requested assistance in obtaining a locksmith position with the VA Medical Center in Cheyenne. While the veteran's statements are considered competent with respect to his description of his symptoms, they are contradicted by the essentially normal objective findings during this period. It therefore cannot be said that the service connected conditions "clearly" interfered with normal employability. Such interference, to the extent it existed at all, is not clearly established. As such, the Board concludes that a compensable rating is not in order. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for gastrointestinal disability as secondary to medication taken for service- connected left heel disability is denied. Entitlement to service connection for sepsis residuals as secondary to service-connected sinusitis is denied. Entitlement to an initial rating in excess of 30 percent for major depressive disorder is denied. Entitlement to an initial compensable evaluation for residuals of a left knee injury prior to September 2, 2006, and an initial rating higher than 10 percent from September 2, 2006 to the present, is denied. Entitlement to an initial rating in excess of 10 percent for left trochanter bursitis prior to September 2, 2006, and an initial rating higher than 20 percent from September 2, 2006, to the present, is denied. Entitlement to a compensable evaluation for multiple, noncompensable service-connected disabilities under the provisions of 38 C.F.R. § 3.324 for the period from January 17, 1978, to June 6, 1989, is denied. REMAND In its December 1999 Remand (Volume 3), the Board instructed that the veteran should be afforded an orthopedic examination by a physician with appropriate expertise to determine the nature, extent and etiology of any pes cavus of the left foot with tarsal tunnel syndrome. More specifically, the examiner was asked to provide an opinion as to whether it is at least as likely as not that any such disability is etiologically related to service or was caused or chronically worsened by the veteran's service-connected left heel disability. As noted by the Court in its April 2006 Memorandum Decision, such an opinion was not provided in the November 2000 examination report (Volume 3). The Court has held that RO compliance with a remand is not discretionary, and that, if the RO fails to comply with the terms of a remand, another remand for corrective action is required. Stegall v. West, 11 Vet. App. 268 (1998). Also in the April 2006 Memorandum Decision, the Court cited its holding in Tropf v. Nicholson, 20 Vet. App. 317 (2006) for the proposition that hyphenated ratings are appropriate only for diseases, and may not be assigned for injuries. The Court also cited Tropf and Esteban v. Brown, 6 Vet. App. 259, 261(1994) for the proposition that a hyphenated rating is improper where it is used to assign a single rating to two different disabling conditions which should be rated separately. In this case, the veteran's callosities of the plantar surface of the left heel have been rated under the hyphenated Diagnostic Codes 5310-5284. Diagnostic Code 5284 is a general code which rates foot injuries on the basis of whether they are moderate, moderately severe, or severe; and Diagnostic Code 5310 deals with injuries of the intrinsic muscles of the foot. The Court instructed that the Board should consider whether the ratings assigned in this case were compliant with the holding in Tropf. The Board notes that the veteran has been diagnosed with medial plantar neuroma, which is not specifically service connected, but which has been medically attributed by M.R.R., MD, in November 2000 (Volume 3) to the service-connected callosities of the plantar surface of the left heel. However, M.R.R. did not describe the extent of impairment due to the neuroma, and a separate rating for neurological impairment has not been assigned. The Board finds that an examination and medical opinion is necessary to determine the severity and manifestations of any neurological impairment of the left foot that is attributable to the service-connected left heel disability. The Board is bound by the findings contained in the joint motion, as adopted by the Court. See Chisem v. Gober, 10 Vet. App. 526, 527-8 (1997) [under the "law of the case" doctrine, appellate courts generally will not review or reconsider issues that have already been decided in a previous appeal of the same case, and therefore, Board is not free to do anything contrary to the Court's prior action with respect to the same claim]. The separate issue of entitlement to a TDIU is inextricably intertwined with the remanded issues, and the directed development will encompass that issue. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation]. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The RO or the AMC should send the veteran a letter requesting him to provide any pertinent evidence in his possession and any outstanding medical records pertaining to treatment or evaluation of his left foot during the period of this claim or the identifying information and any necessary authorization to enable VA to obtain such records on his behalf. 2. The RO or the AMC should undertake appropriate development to obtain any pertinent evidence identified but not provided by the veteran. If the RO or the AMC is unsuccessful in its efforts to obtain any such evidence, it should so inform the veteran and his attorney and request them to submit the outstanding evidence. 3. Thereafter, the veteran should be afforded orthopedic and neurological examinations by (a) physician(s) with appropriate expertise to determine the nature, etiology, and extent of impairment resulting from the veteran's various service-connected and non-service- connected left foot disabilities, including callosities of the plantar surface of the left heel, medial plantar neuroma, and pes cavus of the left foot with tarsal tunnel syndrome. All indicated studies should be performed, and the examiner(s) is/are to set forth all findings in detail. An examination of the service-connected callosities of the plantar surface of the left heel and left foot neurological impairment should be completed. The nature and extent of any neurological impairment of the left foot that is attributable to the service-connected callosities of the plantar surface of the left heel should be described. The affected nerves should be identified and all associated symptomatology noted. The examiner should also provide an opinion concerning the impact of the service-connected disability (including medications taken in treatment thereof) on the veteran's ability to work. An opinion is requested as to whether there is a probability of at least 50 percent that the veteran's pes cavus of the left foot with tarsal tunnel syndrome is etiologically related to his military service or was caused or chronically worsened by his service-connected callosities of the plantar surface of the left heel. Any other disabilities of the left foot should be identified, and their relationship, if any, to the service- connected callosities of the plantar surface of the left heel should be described. The complete rationale for all opinions expressed should also be provided. The claims folders, including a copy of this remand, must be made available to and reviewed by the examiner. 4. The RO or the AMC should also undertake any other development it determines to be warranted. 5. Then, the RO or the AMC should readjudicate the veteran's claims of entitlement to service connection for pes cavus of the left foot, 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, and entitlement to a TDIU. If any benefit sought on appeal is not granted to the veteran's satisfaction, he and his attorney should be provided a supplemental statement of the case and an appropriate period of time for response before the case is returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until he is otherwise notified but he has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This case 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. 2007). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs