Citation Nr: 22012097 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 19-15 449 DATE: March 2, 2022 ORDER 1. Entitlement to service connection for a cervical spine disability is denied. 2. Entitlement to service connection for a lumbar spine disability is denied. 3. Entitlement to service connection for a right knee disability is denied. 4. Entitlement to service connection for a left knee disability is denied. REMANDED 5. Entitlement to service connection for residuals of a head trauma, to include headaches, is remanded. FINDINGS OF FACT 1. The evidence persuasively weighs against finding that the current cervical spine disability had its onset in service or is otherwise related to service. 2. The evidence persuasively weighs against finding that the current lumbar spine disability had its onset in service or is otherwise related to service. 3. The evidence persuasively weighs against finding that the current right knee disability had its onset in service or is otherwise related to service. 4. The evidence persuasively weighs against finding that the current left knee disability had its onset in service or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from September 1984 to October 1992. The Veteran testified before the undersigned Veterans Law Judge (VLJ) during a virtual Board hearing in July 2021. A transcript of the hearing is of record. During the hearing, the VLJ agreed to hold the record open for the Veteran to submit additional evidence. In September 2021, additional medical evidence was submitted by the Veteran and has been associated with the claims file since the hearing with a waiver of review of this new evidence in the first instance by the Agency of Original Jurisdiction (AOJ). The Board appreciates the Veteran's assistance with obtaining additional evidence. Service Connection, Generally The Veteran contends that his cervical spine, lumbar spine, and bilateral knee disabilities are caused by an in-service motor vehicle accident. Specifically, he has asserted throughout the appeal, including in a June 2016 statement and at the July 2021 Board hearing, that he had a motor vehicle accident in December 1989 during which the car flipped over six or seven times. He contends that he injured his neck, back, and knees in the accident and that his spinal and knee symptoms have gotten worse since that time. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Disabilities diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Furthermore, pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In the April 2015 Fully Developed Claim (Compensation) (VA Form 21-526EZ), the Veteran stated that he was seeking service connection for degenerative joint disease (DJD) in the cervical spine and bilateral knees, which is a chronic disease for VA purposes. However, after an extensive review of the claims file, including VA and private treatment records, the record does not show that the Veteran has been diagnosed with DJD in his spine or knees. Thus, the provisions related to chronic diseases do not apply to these disabilities. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a); Walker, 708 F.3d at 1331. 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. § 5107; 38 C.F.R. § 3.102. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. - 2. Cervical and Lumbar Spine Disabilities The Veteran contends that his current cervical and lumbar spine disabilities are caused by the December 1989 in-service car accident during which the car he was driving flipped over several times. For example, during the July 2021 Board hearing, he testified that he sustained injuries to his neck and back in this accident, and, although he was treated at a Navy Hospital on the day of the accident, he started noticing back trouble and painful symptoms days and weeks after the accident. He testified that he had not had any additional accidents or injuries following the December 1989 motor vehicle accident, and that his symptoms have gotten worse throughout the years. The Board has carefully reviewed the evidence of record and finds the evidence persuasively weighs against the claims for service connection for cervical and lumbar spine disabilities. The reasons follow. As to evidence of current disabilities, April 2019 VA examination reports show the Veteran has been diagnosed with lumbosacral strain and a cervical strain. Thus, the first element of service connection, i.e., the presence of a current disability, is met. Regarding the second element of service connection, i.e., evidence of a disease or injury in service, the Veteran's service treatment records show that he was involved in two motor vehicle accidents during his active duty. Specifically, an October 1986 service consultation sheet shows that the Veteran's cervical spine was evaluated following a motor vehicle accident, which occurred that morning. The Veteran was the driver and he reported that he struck the steering wheel with his face. Upon evaluation, he denied any cervical spine discomfort and the cervical spine was negative for fractures or dislocation. The medical professional noted that the Veteran had full range of motion of the cervical spine and did not have paraspinal spasms. An x-ray report of the cervical spine was negative. The Veteran was noted to have some loose incisors with mild periodontal bleeding. The impression was status-post motor vehicle accident with the cervical spine cleared. An April 1988 service reenlistment Report of Medical Examination shows that clinical evaluation of the Veteran's spine and other musculoskeletal system was noted to be normal. In a September 1989 dental health questionnaire, the Veteran denied having painful joints. A December 1989 treatment record from the Navy Hospital in Pensacola, Florida shows that the Veteran reported that he rolled the car over six times going over 65 miles per hour. There was a contusion noted on the left leg, and the Veteran complained of a headache and left-sided head injury. The medical professional documented that the Veteran was a restrained driver during the accident and that the car rolled several times. There was no loss of consciousness but the Veteran complained of left lower extremity pain and mild pain over the left eye. Notably, he expressly denied any neck, back, or abdominal pain. A physical evaluation of his cervical spine and left lower extremity showed no fractures or dislocations. The Veteran was discharged from the hospital the same date. The Navy Hospital's injury notification form from the same date also showed that the Veteran was involved in a motor vehicle accident in which he flipped his car over six times. The nature and extent of the injury statement shows that the Veteran had contusions and abrasions sustained from the accident. The Veteran was restricted to limited duty, the disability was considered temporary, and the estimated loss of time from duty as a result of the injury was minimal to none. Service dental health questionnaires from August 1990 and July 1992 show that the Veteran denied having painful joints. The Veteran's September 1992 service separation evaluation shows that the Veteran's spine and other musculoskeletal system was again noted to be normal. The Veteran denied a history of swollen or painful joints, broken bones, arthritis, bone, joint, or other deformity, recurrent back pain, and periods of unconsciousness. Following service, the Veteran was seen in May 1998 by a non-VA chiropractor for lower back pain. He reported that he had back pain for four days after making a certain move with his back when playing with his children. The Veteran reported at the time that he previously was involved in a car accident seven years prior, but he stated that he did not have any injuries from this accident except a cut on his knee. The Veteran was seen by this chiropractor again in November 1998 and March 2000, during which he received treatment for painful, stiff, or sore symptoms in his lower back. The record shows that the Veteran was seen in October 2014 at a VA medical facility during which his neck and cervical spine were noted to be normal. The Veteran filed the present claims for service connection for cervical and lumbar spine disabilities in April 2015. In a June 2015 VA social worker's note, the Veteran complained of problems with his neck and reported going to physical therapy for these symptoms. He also reported that he was a postal worker employee for the previous 18 years. In a June 2015 private treatment record, the Veteran complained of constant back and neck pain. He reported that although his neck and back pain has increased over time, there was no injury that caused it. The medical professional noted that the mechanism of injury was gradual onset or insidious. X-ray studies of the spine showed degenerative disc disease (DDD) at the L4-L5 and L5-S1 spinal segments. This medical professional again noted that there was no injury and that the neck and back pain had increased over time in a subsequent June 2015 treatment record. In a September 2015 private treatment record, the Veteran reported that he was involved in a motor vehicle accident in the 1990s and that he has had back and knee pain since that time. Although the medical professional noted that the Veteran was involved in the motor vehicle accident 15 years prior, the record shows that the accident occurred approximately 25 years prior to the September 2015 treatment note. In September 2016, the Veteran submitted statements from his mother, son, and previous fiancée in which these individuals described the Veteran's joint pain for many years. In particular, the Veteran's mother and fiancée recounted the conversations they had with the Veteran on the day of the December 1989 accident and his complaints of head pain. Likewise, the Veteran asserted in a September 2016 statement in connection with a claim for service connection for posttraumatic stress disorder (PTSD) that he was in a lot of pain following the accident, but that the pain was the worst in his back, neck, and both knees. He stated that he received a scar on his left leg that measured approximately four inches long. The Board notes that service connection for PTSD and a left leg scar has been granted. In April 2019, the Veteran was afforded VA examinations for this cervical and lumbar spine disabilities, during which the examiner reviewed the Veteran's records, noted his self-reported history, and provided a thorough examination of the spine. The examiner opined that the claimed cervical and lumbar spine disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner determined that the medical record did not support a cervical or a lumbar spine disability that was incurred due to the December 1989 motor vehicle accident. The examiner explained that at the time of the accident, there was no neck or back pain reported despite a rollover mechanism in the accident. The examiner noted that there are no other reported complaints reviewed in the medical record. Therefore, the examiner concluded that it is less likely than not that the cervical and lumbar spine disabilities were caused by the motor vehicle accident during service. Given this evidence, the Board finds that the evidence persuasively weighs against finding that the current cervical and lumbar spine disabilities had their onset in service or are otherwise related to service. The Board accords high probative value to the April 2019 medical opinions, as the examiner reviewed the file and provided opinions that were based upon the specific facts of the Veteran's case and medical principles. This examiner noted that although the Veteran currently has cervical and lumbar spine disabilities, the evidence, including the December 1989 service treatment record immediately following the motor vehicle accident, showed that the Veteran did not complain of neck or back pain at the time. The Board has considered the Veteran's lay statements throughout the appeal, as well as the statements made by his former fiancée, mother, and son. The Veteran further testified during the July 2021 Board hearing that pain started in his cervical and lumbar spine days and weeks following the December 1989 motor vehicle accident. However, in addition to denying having any painful symptoms in his cervical or lumbar spine at the time of the December 1989 rollover accident, as documented in the contemporaneous Navy Hospital treatment record, subsequent service treatment records refute the Veteran's assertions that he had painful neck and back symptoms following the car accident. For example, he denied having painful joints in August 1990 and July 1992 service Dental Health Questionnaires. He also denied a history of swollen or painful joints, broken bones, arthritis, bone, joint, or other deformity, recurrent back pain, and periods of unconsciousness during the September 1992 service separation evaluation, which showed that clinical evaluations of the neck and spine were both normal. The Board affords more probative value to the contemporaneous records, which show affirmative denials by the Veteran of neck and low back pain immediately following the accident and his continued denials of joint pain and his denial of recurrent back pain up until the point of his service discharge in 1992, which was almost three years after the accident. The denials at the time of the accident and following the accident for almost three years are affirmative evidence that the Veteran was not having symptoms in his cervical and lumbar spine. This is not a situation where there is an absence of evidence, but rather where the Veteran denied symptoms he now claims he was having. Thus, the Veteran's allegations of the onset of cervical and lumbar spine pain at the time of the 1989 accident and continuing pain during service are not credible. The record shows that the first instance of treatment for back pain symptoms following active duty was from the May 1998 private chiropractor's note, which shows that he was being treated for lumbar spine pain that was present for four days following a post-service incident while playing with his children. The Veteran reported the 1989 automobile accident and stated that he received no injuries other than a cut on his knee, which further supports the finding that the Veteran did not sustain injuries to his cervical and lumbar spine at the time of the accident and was not having neck and low back symptoms in the years following service. He reported the onset of his back pain as being recent. These facts do not support evidence of in-service injuries with ongoing symptoms in the years following service discharge. As to the cervical spine, the record shows that the Veteran did not complain of any abnormal cervical spine symptoms until he filed the present claim for service connection in April 2015, and an earlier, October 2014 VA treatment record shows that his neck and cervical spine were documented as normal. These facts do not support a finding of chronic cervical spine pain since service. The Board has also considered the Veteran's testimony during the July 2021 Board hearing that his current cervical and lumbar spine disabilities were caused by the December 1989 motor vehicle accident. Although the Veteran is competent to report symptoms that he perceived through his own senses, such as the in-service car accident and any subsequent pain symptoms in his neck or back, he is not competent to offer an opinion as to the cause of this type of cervical and lumbar spine disabilities due to the medical complexity of the matters involved. Cervical and lumbar strains require specialized training for a determination as to diagnosis, causation, and progression, and are therefore not susceptible to lay opinions on causation or aggravation. Thus, the Veteran is not competent to render an opinion or attempt to present lay assertions to establish the cause of these disorders. The Board determines that the findings and opinions of the April 2019 VA examiner, which are competent on the issue of causation of medically complicated matters, are highly probative evidence regarding the cause of the Veteran's current cervical and lumbar spine disabilities. The examiner based the opinion on the same facts that the Board finds are accurate, which are that the Veteran denied neck and low back injuries at the time of the accident and did not have ongoing symptoms following the accident either during service or in the years following service discharge. Thus, the opinion was based on an accurate factual predicate. At the present time, there is no competent evidence establishing a nexus between the current cervical and lumbar spine disabilities and the Veteran's service, to include the December 1989 motor vehicle accident, to weigh against the negative April 2019 VA opinions. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for cervical and lumbar spine disabilities is warranted. Rather, the evidence persuasively weighs against the service-connection claims for cervical and lumbar spine disabilities. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 3. - 4. Right and Left Knee Disabilities The Veteran contends that his current right and left knee disabilities were caused by the in-service motor vehicle accident. For example, the Veteran contends that he injured his knees in the December 1989 car accident where he tried to avoid another car and his car flipped up the hill several times. Moreover, he testified during the July 2021 Board hearing that his bilateral knee symptoms have been getting worse over the years since the accident. The Board has carefully reviewed the evidence of record and finds the evidence persuasively weighs against the claims for service connection for right and left knee disabilities. The reasons follow. As to evidence of a current disability, the Veteran has been diagnosed with a right and a left knee strain during the April 2019 VA examination. Thus, the first element of service connection, i.e., the presence of a current disability, is met. Regarding the second element of service connection, i.e., evidence of a disease or injury in service, the Veteran's service treatment records show that he was involved in two motor vehicle accidents during active duty. For example, an October 1986 service treatment record shows that he hit his head against the steering wheel while involved in an accident. Although the Veteran's teeth, mouth, and cervical spine were evaluated, these records do not show that he complained of right or left lower extremity symptoms, including in his knees. An April 1988 service reenlistment Report of Medical Examination shows that clinical evaluation of the Veteran's lower extremities were found to be normal. The Veteran denied a history of painful joints in a September 1989 dental health questionnaire. December 1989 service treatment records show that the Veteran was involved in a second motor vehicle accident while driving with a restraint. The Veteran's car rolled over or flipped six times. The Veteran complained of left lower extremity pain and a blow to the head, but denied any loss of consciousness, neck, back, or abdominal pain. A physical evaluation showed that the left lower extremity did not have any fracture or dislocation, and the examiner noted that the left knee was stable and had full range of motion. The examiner noted the Veteran had several linear abrasions on the lower left leg anterior to the lateral malleolus. The record shows that the Veteran was granted service connection for a residual scar of the left leg status-post motor vehicle accident. These December 1989 service treatment records further show that the Veteran had contusions and abrasions sustained from the accident, which included the injury to the left side of the Veteran's head. He was restricted to limited duty, the disability was considered temporary, and the estimated loss of time from duty as a result of injury was minimal to none. Post-accident service treatment records show that the Veteran denied any painful joints in August 1990 and July 1992 dental health questionnaires. He also denied a history of swollen or painful joints, broken bones, arthritis, bone, joint, or other deformity, "trick" or locked knees, and periods of unconsciousness in the September 1992 service separation Report of Medical History. The Report of Medical Examination further showed that the Veteran's lower extremities were assessed as normal, apart from a scar. Post-service treatment records show that the Veteran was not treated for or complained of knee symptoms until an October 2014 VA treatment record that showed his complaint of right knee pain and stiffness. The Veteran filed the present claims for service connection for bilateral knee disorders in April 2015. A September 2015 private treatment record shows that the Veteran reported that he was involved in a motor vehicle accident in the 1990s in the military and that he had left knee pain at that time. He made very similar statements in an April 2016 private treatment record. In a June 2016 statement, the Veteran asserted that his current bilateral knee pain is due to the December 1989 in-service motor vehicle accident. He made very similar assertions in a September 2016 statement. He submitted September 2016 statements from his mother, son, and previous fiancée, who described witnessing the Veteran's joint pain for many years. Following an-in person examination, review of the Veteran's records, and notation of his self-reported history, an April 2019 VA examiner opined that the right and left knee strains were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner determined that the medical record did not support right or left knee disabilities that were incurred status-post the motor vehicle accident in December 1989. The examiner explained that at the time of the accident, there was no right or left knee pain reported despite a rollover mechanism in the accident. The examiner noted that there were multiple abrasions noted on the left leg but an overall negative knee examination, bilaterally. The examiner noted that there are no other reported complaints reviewed in the medical record. Therefore, the examiner concluded that it is less likely than not that the right and left knee disabilities were caused by the motor vehicle accident during service. Given this evidence, the Board finds that the evidence persuasively weighs against finding that the current right and left knee disabilities had their onset in service or are otherwise related to service, to include the December 1989 motor vehicle accident. The Board has considered the Veteran's lay statements throughout the appeal that he had injuries to his knees in the accident and that his bilateral knee symptoms became worse over the years. However, in addition to the documentation in the contemporaneous Navy Hospital treatment record that showed the Veteran's left knee was stable and had full range of motion, service treatment records following the accident refute the Veteran's assertions that he had painful knee symptoms following the accident. For example, he denied having painful joints in August 1990 and July 1992 service Dental Health Questionnaires. He also denied a history of swollen or painful joints, broken bones, arthritis, bone, joint, or other deformity, and "trick" or locked knee during the September 1992 service separation evaluation, which showed that his lower extremities were clinically normal, apart from a scar on the left leg. At the time of the accident, the Veteran reported left leg pain and did not report right leg pain, which the Board finds is evidence that there was no right knee pain at that time; otherwise, the Veteran would have reported it. The Board affords more probative value to the contemporaneous records, which show that the Veteran's left knee was examined at the time of the accident and found to be stable with full range of motion, and the Veteran's continued denials of joint pain up until the point of his service discharge in 1992, which was almost three years after the accident, than to the current allegations of chronic symptoms since the accident. This is not a situation where there is an absence of evidence, but rather where the Veteran denied symptoms he now claims he was experiencing. Thus, the Veteran's allegations of the onset of bilateral knee pain at the time of the 1989 accident and continuing pain during service are not credible. When treated in 1998 for back pain, the Veteran described the auto accident as not causing any injuries except a cut on his knee, which supports that the Veteran was not experiencing chronic symptoms from the in-service auto accident, including bilateral knee symptoms. Overall, the record shows that the first instance of treatment for right knee pain was in October 2014, and that the Veteran complained of left knee symptoms for the first time in the April 2015 application for service connection. A 20-plus-year between separation from active duty and treatment or complaints of right and left knee symptoms is evidence against a finding that the current bilateral knee disabilities had their onset in service. The Board has also considered the Veteran's testimony during the July 2021 Board hearing that his bilateral knee disabilities were caused by the December 1989 motor vehicle accident. Although he is competent to report symptoms that he perceived through his own senses, such as the in-service car accident and any subsequent pain symptoms in his left leg or knees, he is not competent to offer an opinion as to the cause of this type of knee disabilities due to the medical complexity of the matters involved. Right and left knee strains require specialized training for a determination as to diagnosis, causation, and progression, and are therefore not susceptible to lay opinions on causation or aggravation. Thus, the Veteran is not competent to render an opinion or attempt to present lay assertions to establish the cause of these disorders. The Board determines that the findings and opinions of the April 2019 VA examiner, which are competent on the issue of causation of medically complicated matters, are highly probative evidence regarding whether the current disabilities had their onset in service. The Board accords high probative value to these medical opinions, as the examiner reviewed the file and provided opinions that were based upon the specific facts of the Veteran's case and medical principles. The examiner based the opinion on the same facts that the Board finds are accurate, which is that the Veteran did not experience bilateral knee injuries at the time of the accident and did not have ongoing bilateral knee symptoms following the accident. The Board finds that the complaint of lower leg pain at the time of the accident is not the same as a left knee injury. The Veteran's knee was examined at that time and had full range of motion and was stable. This examiner noted that although the Veteran currently has bilateral knee strains, the evidence, including the December 1989 service treatment record following the motor vehicle accident, showed that the examination of the Veteran's knees at the time was negative, even though multiple abrasions were noted on the left leg. Thus, the opinion was based on an accurate factual predicate. At the present time, there is no competent evidence establishing a nexus between the current right and left knee disabilities and the Veteran's service, to include the December 1989 motor vehicle accident, to weigh against the negative April 2019 VA opinions. For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlements to service connection for right and left knee disabilities are warranted. Rather, the evidence persuasively weighs against entitlements to service connection for right and left knee disabilities. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch, 21 F.4th at 776. REASONS FOR REMAND 5. Residuals of head trauma The Board must remand the Veteran's claim for entitlement to service connection for residuals of a head trauma, to include headaches, to afford him a VA examination. VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, and there is insufficient medical evidence of record to decide the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon, 20 Vet. App. at 79. The Veteran contends that he currently has headaches that were caused by the December 1989 motor vehicle accident. In a May 2019 VA nurse practitioner statement, she wrote that the Veteran complained of migraine headaches, which occurred three to four times per month and for which he took ibuprofen medication. Moreover, the Veteran testified during the July 2021 Board hearing that he had headaches and that he has been taking migraine medication for the previous three to four years. He has also asserted throughout the appeal that his headaches began following an in-service motor vehicle accident in December 1989 during which he sustained an injury to this head but with no loss of consciousness. The Board notes that the Veteran was involved in another car accident in October 1986 during which his head hit the steering wheel and caused an injury to his mouth, to include loose incisors and paradental bleeding. The Veteran has not been afforded a VA examination in connection with his claim for entitlement to service connection for residuals of a head trauma, to include headaches. Given the above, the Board finds that a VA examination is necessary to address the nature and cause of his current headache symptoms, if any are present. See McLendon, 20 Vet. App. 79. As the Board is remanding the claim, it will also request that updated VA treatment records be added to the Veteran's claims file. The matter is REMANDED for the following action: 1. Upload the Veteran's VA treatment records from October 2019 to the present. 2. Schedule the Veteran for an examination to assist in determining the nature and cause of any current residuals of a head trauma, to include headaches, if any such residuals are present. All appropriate tests should be accomplished, and all clinical findings should be reported in detail. The AOJ is asked to provide a copy of the below facts to the examiner. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record of where this evidence is located: The Veteran served on active duty from September 1984 to October 1992. The Veteran is claiming that after a December 18, 1989 in-service motor vehicle accident, in which the car he was driving rolled over six or seven times and in which he injured his head, he developed headaches, which are currently symptomatic." See VBMS entry with document type, "Hearing Transcript," receipt date 07/29/2021. October 29, 1986 service treatment records show that the Veteran was involved in a motor vehicle accident that morning, where he was the driver. He reported that he struck his face and mouth against the steering wheel during the accident. His cervical spine was cleared of any symptoms, but he was noted to have loose lower incisors and mild periodontal bleeding. He was sent to dental for treatment. See VBMS entry with document type, "STR - Medical," receipt date 06/05/2015, pp. 5, 6. An April 1988 service reenlistment Report of Medical Examination shows that clinical evaluations of the Veteran's head, face, neck, and scalp were normal. See VBMS entry with document type, "Medical Treatment Record-Government Facility," receipt date 04/20/2015, p. 1 (items 18 & 38). A Pensacola, Florida Navy Hospital treatment record, dated December18, 1989, shows that the Veteran was involved in a motor vehicle accident that day, in which his car rolled over six times going 65 miles per hour. The Veteran complained of a headache and a left-sided head injury at the time, but there was no loss of consciousness. He was noted to have mild pain over the left eye. See VBMS entry with document type, "Medical Treatment Record-Government Facility," receipt date 09/20/2021. September 1992 service separation report of medical examination shows that clinical evaluations of the Veteran's head, face, neck, and scalp were normal. See VBMS entry with document type, "Medical Treatment Record-Government Facility," receipt date 04/20/2015, p. 3 (items 18 & 38). In the September 1992 service separation Report of Medical History from the same date, the Veteran denied having a history of a head injury and periods of unconsciousness. See VBMS entry with document type, "STR - Medical," receipt date 06/05/2015, pp. 10-11 (item 11, first and third columns). An October 2014 VA treatment record shows that a review of systems was negative for headache and scalp lesions. See VBMS entry with document type, "CAPRI," receipt date 09/18/2019, p. 62. An April 2016 private treatment record shows that the Veteran was there complaining of lower back pain. A review of systems performed at that time showed the Veteran denied any recent fever, chills, headache, or change in weight. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 09/21/2021, p. 22. September 2016 statements from the Veteran's mother and former fiancée discussing their conversations with the Veteran on the day of the December 1989 motor vehicle accident during which the Veteran reported that his head hurt. See two separate VBMS entries with document type, "Buddy/Lay Statement," receipt date 09/28/2016. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. Based upon a review of the evidence and sound medical principles, the VA examiner should: (a.) Diagnose all of the Veteran's current residuals of an in-service head trauma, to include headaches, if any such residuals are present. (b.) Provide an opinion as to whether the Veteran's current residuals of a head trauma, to include headaches, if any such residuals are present, had their onset in service, or were caused by or are otherwise related to service, to include the October 1986 or December 1989 motor vehicle accidents. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Hodzic, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.