J.S. and U.S. Postal Service, Main Post Office, Jacksonville, FL (Board decision, November 22, 2010)

ECAB final decision. The Board affirmed OWCP’s denial of J.S.’s traumatic injury claim for a back condition. Under 20 C.F.R. § 501.6(d), this Board decision becomes final 30 days after issuance unless the Board fixed a different period in it. A party may petition the Board for reconsideration within 30 days unless this decision specifies another period, under 20 C.F.R. § 501.7(a). FECA compensation decisions are generally not subject to court review under 5 U.S.C. § 8128(b).

Plain-English summary

J.S., a postal clerk, reported increased back pain after working on a mail processing machine on February 2, 2009. OWCP accepted that she performed the work activities but denied her injury claim. The Board found that her physicians diagnosed spinal conditions without adequately explaining how the specific work that day caused or aggravated them. An early medical note also recorded that she knew of no cause for the increased pain, which conflicted with her later account of lifting heavy trays. The Board affirmed the denial because the medical evidence did not establish a causal connection.

Decision snapshot

• Authority: FECA traumatic injury causation requirements.
• Outcome: February 18, 2010 and August 25, 2009 OWCP decisions affirmed; work-related back injury not established.
• Key point: The medical opinions lacked a reasoned link between the accepted work activities and the diagnosed spinal conditions.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
J.S., Appellant
)
)
and ) Docket No. 10-1094
) Issued: November 22, 2010
U.S. POSTAL SERVICE, MAIN POST OFFICE,
)
Jacksonville, FL, Employer
)
__________ )

Appearances: Case Submitted on the Record
Alan J. Shapiro, Esq., for the appellant
Office of Solicitor, for the Director

DECISION AND ORDER

Before:
COLLEEN DUFFY KIKO, Judge
MICHAEL E. GROOM, Alternate Judge
JAMES A. HAYNES, Alternate Judge

JURISDICTION

On March 18, 2010 appellant filed a timely appeal from the February 18, 2010 decision of the Office of Workers’ Compensation Programs denying her traumatic injury claim. Pursuant to 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over the merits of this case.

ISSUE

The issue is whether appellant sustained a traumatic injury on February 2, 2009 while in the performance of duty.

FACTUAL HISTORY

On June 25, 2009 appellant, then a 52-year-old clerk, filed a traumatic injury claim alleging that on February 2, 2009 she sustained a herniated disc and bulging and annular tear due to repetitive lifting of trays of mail. Her supervisor observed appellant lifting mail trays on that day.

On February 4, 2009, Dr. L. Alan Smith, a Board-certified general surgeon, noted that appellant had a history of low and mid back pain. On February 2, 2009 appellant experienced a marked increase in low back pain. She knew of no precipitating cause. Dr. Smith placed her off work from February 3 to 6, 2009. On February 9, 2009 he noted that a magnetic resonance imaging (MRI) scan revealed an extruded disc at L4-5. Dr. Smith diagnosed sciatica.

On February 11, 2009 Dr. Ellen C. Sackett, a Board-certified family practitioner, advised that appellant had a work-related back injury in 2008 that improved but appellant’s symptoms worsened on February 2, 2009 when she worked on a machine all day. On April 28, 2009 she diagnosed a herniated lumbar disc.

By letter dated July 13, 2009, the Office asked appellant for additional information, including a detailed description of the February 2, 2009 work activities and medical evidence containing a history, diagnosis and rationalized explanation as to how the diagnosed condition was causally related to the February 2, 2009 work incident.

On June 22, 2009 Dr. Sackett stated that she first saw appellant on April 22, 2008 for an injury the day before when appellant lifted a heavy tray of mail. A June 9, 2008 MRI scan revealed a herniated disc at L4-5. Appellant’s symptoms worsened and a repeat MRI scan on April 10, 2009 revealed a disc bulge at L2-3, annular tear at L3-4 with a disc bulge and a herniated disc at L4-5. Dr. Sackett opined that these injuries were a direct result of the work incidents on April 21, 2008 and February 2, 2009. On July 29, 2009 she noted that appellant had a history of back pain following a motor vehicle accident in 1996. The June 9, 2008 MRI scans revealed an L4-5 herniated disc and a disc bulge at L3-4. Appellant was treated with physical therapy and trigger point injections. On February 9, 2009 she had increased pain. On February 11, 2009 appellant reported left lower extremity pain after working on machines all day on February 2, 2009.

On July 24, 2009 Dr. Smith stated that on July 7, 2008 he saw appellant for low and mid back pain and right leg radicular pain that she believed were caused by her job. He noted that on an unspecified date she was lifting trays of mail weighing at least 30 pounds. Appellant’s preexisting back problems were in remission at the time of her injury. Dr. Smith provided findings on physical examination. He noted that MRI scan studies taken on June 9, 2008 revealed an L3-4 disc bulge with facet arthrosis and an L4-5 paracentral disc extrusion with facet arthrosis. Dr. Smith treated appellant with physical therapy and trigger point injections for a diagnosis of lumbar disc syndrome with sciatic neuralgia.

By decision dated August 25, 2009, the Office denied appellant’s claim on the grounds that the evidence did not establish that she sustained an injury on February 2, 2009 while in the performance of duty.

On September 15, 2009 appellant requested a hearing that was held on December 9, 2009. In a September 13, 2009 report, Dr. Sackett advised that she saw appellant on February 11, 2009 for a history of working all day on a machine. Appellant had severe pain and numbness in her left leg. Her symptoms and physical examination were consistent with her history of an injury at work. An MRI scan revealed a herniated disc at L4-5 on the left with an extruded fragment and encroachment on the left L4 nerve root. Dr. Sackett opined that appellant’s symptoms were caused by her injury at work on February 2, 2009.

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 By decision dated January 28, 2010, the Office denied modification of the September 18, 2009 decision.

LEGAL PRECEDENT

To determine whether a federal employee has sustained a traumatic injury in the performance of duty, it first must be determined whether the fact of injury has been established. There are two components involved in establishing the fact of injury. First, the employee must submit sufficient evidence to establish that he or she actually experienced the employment incident at the time, place and in the manner alleged.1 Second, the employee must submit medical evidence to establish that the employment incident caused a personal injury.2 An employee may establish that the employment incident occurred as alleged but fail to show that his or her disability or condition relates to the employment incident.

To establish a causal relationship between an employee’s condition and any disability claimed and the employment event or incident, he or she must submit rationalized medical opinion evidence based on a complete factual and medical background supporting such a causal relationship. Rationalized medical opinion evidence is medical evidence which includes a physician’s opinion on the issue of whether there is a causal relationship between the employee’s diagnosed condition and the compensable employment factors. The opinion of the physician must be based on a complete factual and medical background of the employee, must be one of reasonable medical certainty and must be supported by medical rationale explaining the nature of the relationship between the diagnosed condition and the specific employment factors identified by the claimant.3

ANALYSIS

The Office accepted that on February 2, 2009 appellant worked all day processing mail on a machine. The issue is whether appellant sustained a medical condition as a result of the February 2, 2009 incident.

On February 4, 2009 Dr. Smith noted that appellant had a history of low and mid back pain. On February 2, 2009 appellant experienced a marked increase in low back pain. She knew of no precipitating cause. Appellant stated that she did not know what might have caused her pain on February 2, 2009 conflicts with her subsequent claim of a back injury caused by lifting heavy trays of mail all day. Dr. Smith did not provide a history of the injury or explain how her back condition was caused by activities at work on February 2, 2009. Therefore, this report is not sufficient to establish a work-related injury on February 2, 2009. On February 9, 2009 Dr. Smith noted that an MRI scan revealed an extruded disc at L4-5. He diagnosed sciatica. Dr. Smith did not explain how appellant’s sciatica was causally related to the February 2, 2009 work activities. Consequently, this report does not support appellant’s traumatic injury claim.

1
Bonnie A. Contreras, 57 ECAB 364, 367 (2006); Edward C. Lawrence, 19 ECAB 442, 445 (1968).
2
T.H., 59 ECAB 408 (2008); John J. Carlone, 41 ECAB 354, 356-57 (1989).
3
I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345, 352 (1989).

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On July 24, 2009 Dr. Smith stated that on July 7, 2008 he saw her for back and right leg pain that she attributed to her job. He noted that on an unspecified date appellant was lifting trays of mail weighing at least 30 pounds. Dr. Smith diagnosed lumbar disc syndrome with sciatic neuralgia. He did not provide a complete history or a rationalized explanation as to how her back condition was causally related to the February 2, 2009 work activities. Therefore, this report does not establish a work-related injury on February 2, 2009.

On February 11, 2009 Dr. Sackett noted that appellant had a work-related back injury in 2008 that improved. Appellant’s symptoms worsened on February 2, 2009 when she worked on a machine all day. On April 28, 2009 Dr. Sackett diagnosed a herniated lumbar disc but did not explain how the herniated disc was related to appellant’s work activities on February 2, 2009. This report is not sufficient to establish a work-related back injury on February 2, 2009. On June 22, 2009 Dr. Sackett stated that she first saw appellant on April 22, 2008 for an injury the day before when appellant lifted a heavy tray of mail. An MRI scan revealed a herniated disc at L4-5. Appellant’s symptoms worsened and an April 10, 2009 MRI scan revealed a disc bulge at L2-3, annular tear and disc bulge at L3-4 and a herniated disc at L4-5. Dr. Sackett opined that these injuries were caused by the work incidents on April 21, 2008 and February 2, 2009. She did not, however, describe the nature of the February 2, 2009 work activities or give a rationalized explanation of the cause of the spinal conditions. This report is not sufficient to establish an employment injury on February 2, 2009. On July 29, 2009 Dr. Sackett noted that appellant had increased pain on February 9, 2009. On February 11, 2009 she reported left lower extremity pain after working on machines all day on February 2, 2009. Dr. Sackett did not provide details of appellant’s work on February 2, 2009 or explain how her work factors caused her back condition. On September 13, 2009 she advised that she saw appellant on February 11, 2009 for a history of working all day on a machine. An MRI scan revealed a herniated disc at L4-5 on the left with an extruded fragment and encroachment on the left L4 nerve root. Dr. Sackett opined that appellant’s symptoms were caused by her injury at work on February 2, 2009. She did not, however, provide a rationalized opinion as to how appellant’s work activities on February 2, 2009 could have caused her back condition. Therefore, this report is insufficient to establish that appellant sustained a back injury on February 2, 2009 causally related to factors of her employment.

The Office advised appellant of the medical evidence needed to establish her claim, including a report with a medical history diagnosis and a rationalized explanation as to how the diagnosed condition was causally related to the February 2, 2009 incident. No such evidence was submitted.

Appellant failed to meet her burden of proof to establish that she sustained an injury on February 2, 2009 while in the performance of duty.

CONCLUSION

The Board finds that appellant failed to establish that she sustained a traumatic injury on February 2, 2009 while in the performance of duty.

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 ORDER

IT IS HEREBY ORDERED THAT the decisions of the Office of Workers’ Compensation Programs dated February 18, 2010 and August 25, 2009 are affirmed.

Issued: November 22, 2010
Washington, DC

Colleen Duffy Kiko, Judge
Employees’ Compensation Appeals Board

Michael E. Groom, Alternate Judge
Employees’ Compensation Appeals Board

James A. Haynes, Alternate Judge
Employees’ Compensation Appeals Board

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