T.G. and U.S. Postal Service, Processing & Distribution Center, Birmingham, AL (Board decision, November 25, 2014)

ECAB final decision. The Board affirmed OWCP’s April 16, 2014 denial of T.G.’s injury claim. 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).

Plain-English summary

T.G., a mail processing clerk, reported a right shoulder injury while moving a tray of mail at work. OWCP accepted the incident but found no diagnosed shoulder condition medically linked to it. The Board affirmed. The shoulder reports described pain without a firm diagnosis, and a doctor's later suggestion that repetitive work could cause carpal tunnel syndrome was speculative and did not explain how the single incident caused it.

Decision snapshot

• Authority: Traumatic injury causation under FECA.
• Outcome: April 16, 2014 claim denial affirmed.
• Key point: Reports of shoulder pain and a speculative connection to carpal tunnel syndrome did not establish an injury caused by the accepted incident.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
T.G., Appellant
)
)
and ) Docket No. 14-1543
) Issued: November 25, 2014
U.S. POSTAL SERVICE, PROCESSING &
)
DISTRIBUTION CENTER, Birmingham, AL,
)
Employer
)
__________ )

Appearances: Case Submitted on the Record
Appellant, pro se
Office of Solicitor, for the Director

DECISION AND ORDER

Before:
CHRISTOPHER J. GODFREY, Chief Judge
PATRICIA HOWARD FITZGERALD, Judge
JAMES A. HAYNES, Alternate Judge

JURISDICTION

On June 30, 2014 appellant filed a timely appeal from an April 16, 2014 merit decision of the Office of Workers’ Compensation Programs (OWCP) affirming its July 24, 2013 decision denying his claim. Pursuant to the Federal Employees’ Compensation Act1 (FECA) and 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 has met his burden of proof in establishing that he sustained an injury in the performance of duty.

FACTUAL HISTORY

On March 12, 2013 appellant, then a 55-year-old mail processing clerk, filed a traumatic injury claim alleging that on March 9, 2013 he sustained a right shoulder injury in the

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5 U.S.C. § 8101 et seq. performance of duty. He alleged that his right shoulder popped as he moved a full tray of mail from a bin to a roller. Appellant did not stop work.

In an unsigned March 9, 2013 attending physician’s report (Form CA-16) an unidentified provider noted that appellant had right shoulder weakness and checked the box marked “yes,” indicating that appellant’s injury was caused by factors of his employment.

In a March 9, 2013 disability status report, Dr. David Pigott, Board-certified in emergency medicine, advised appellant to refrain from heavy lifting at work until March 11, 2013.

Appellant submitted several duty status reports (Form CA-17). In an April 19, 2013 duty status report, Dr. Michael Blum, a Board-certified orthopedic surgeon, advised that appellant had right shoulder pain and that he should limit reaching above his shoulder to two hours a day. On April 27, 2013 appellant accepted an offer of modified assignment that limited reaching above the shoulders to two hours a day. In a May 3, 2013 duty status report (CA-17), Dr. Blum reiterated the same work restriction. In a May 3, 2013 disability status report, he diagnosed right shoulder pain and advised that appellant was able to work. Dr. Blum further advised appellant to limit reaching above shoulder level for four weeks.

In a May 3, 2013 report, Dr. Blum advised that appellant was experiencing discomfort in the right shoulder. On examination, the rotator cuff was grossly intact, appellant had good motion in both shoulders, and no instability of the right shoulder. He reported some discomfort from his right shoulder to his elbow but Dr. Blum noted that it was vague and nonspecific. There was no muscle atrophy. Dr. Blum recommended that appellant undergo physical therapy for four weeks. He stated that, if appellant’s condition did not improve in four weeks, then he would order magnetic resonance imaging (MRI) scans. Appellant also submitted several physical therapy reports that noted that he injured himself at work when he lifted a tray of mail higher than his chest height.

By letter dated June 17, 2013, OWCP notified appellant that evidence was insufficient to establish his claim. Appellant was advised that initially his claim was administratively approved; however, OWCP would now review the merits of the claim because his medical expenses exceeded $1,500.00. He was further advised that the medical evidence did not include a diagnosis recognized by OWCP because “pain” is considered a symptom not a diagnosis. Appellant was instructed to submit a medical report from his attending physician which included a diagnosis and a statement on causal relationship supported by adequate medical rationale.

In an April 19, 2013 report, Dr. Blum stated that appellant presented with a 10-day history of moderate aching pain in the right shoulder. He advised that the onset of pain was sudden and associated with a specific injury, using a machine and lifting a tray of mail above his shoulder when he heard a pop. Shoulder examination revealed full range of motion, no weakness, intact biceps and triceps and no point tenderness in the acromioclavicular (AC) joint. There was no instability in the right shoulder and the right arm was neurovascularly intact diagnosed with pain in the joint in the shoulder region. Right shoulder x-rays were negative for acute bone abnormality but revealed mildly hooked acromion with some minimal degenerative

2 changes at the AC joint. Dr. Blum diagnosed pain in joint involving the shoulder region and restricted overhead activities with the right shoulder. He also provided work restriction forms.

In a June 10, 2013 report, Dr. Blum noted that appellant had improved since his last visit.
He also noted that appellant’s right shoulder was essentially pain free; however, he was experiencing some periscapular pain. Dr. Blum advised that an x-ray of the neck revealed minimal degenerative changes at the C4-5, C5-6 and C6-7, but indicated that it did not appear significant. On examination, the rotator cuff felt strong, there was no pain with right shoulder range of motion, and appellant had good strength throughout his right rotator cuff, biceps and triceps. Grip strength was symmetrically equal and “very minimally, if any,” weaker on the right. Dr. Blum stated that appellant’s discomfort could be related to neck problems such as herniation or bulging and opined that appellant did not have any intrinsic shoulder residual problems. He noted that appellant had no restrictions based on his shoulder but that he would refer appellant to a neck specialist. In a June 10, 2013 duty status report (Form CA-17), Dr. Blum advised that appellant was able to perform his regular duties without restrictions.

By decision dated July 24, 2013, OWCP denied appellant’s claim finding that the medical evidence did not establish that a medical condition was diagnosed in connection with the claimed event.

In a November 4, 2013 narrative statement, appellant noted that he injured his right arm as he was using a machine to sweep mail from a bin to a tray. He alleged that he injured his right arm as he removed a tray of mail to the roller above him. With his letter appellant provided medical evidence. In an August 14, 2013 diagnostic report, Dr. Michael Geer, Board-certified in internal medicine, advised that a nerve test revealed mild carpal tunnel issues.

In a November 4, 2013 report, Dr. Geer, noted that, on March 9, 2013, appellant was at work sweeping mail from a bin into the appropriate trays when he began to feel right arm pain. He noted first seeing appellant on July 22, 2013 with complaints of right arm weakness. Dr. Geer noted referring appellant for nerve conduction testing, performed on August 8, 2013, which revealed mild carpal tunnel syndrome but no evidence of cervical radiculopathy. He opined that appellant’s “syndrome could certainly have been caused by repetitive motion at the post office.” Dr. Geer cautioned appellant to avoid repetitive motions.

On February 27, 2014 appellant requested reconsideration.

By decision dated April 16, 2014, OWCP denied the claim finding that the medical evidence did not sufficiently explain how the diagnosed condition was causally related to the March 9, 2013 incident. It advised that Dr. Geer did not explain how carpal tunnel syndrome resulted from the initially claimed right shoulder condition. OWCP also noted that Dr. Geer appeared to attribute appellant’s condition to repetitive movements at work, which indicated an occupational disease.

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 LEGAL PRECEDENT

An employee seeking compensation under FECA has the burden of establishing the essential elements of his claim by the weight of reliable, probative, and substantial evidence,2 including that he is an “employee” within the meaning of FECA and that he filed his claim within the applicable time limitation.3 The employee must also establish that he sustained an injury in the performance of duty as alleged and that his disability for work, if any, was causally related to the employment injury.4

To determine whether a federal employee has sustained a traumatic injury in the performance of duty, it first must be determined whether fact of injury has been established. There are two components involved in establishing fact of injury. First, the employee must submit sufficient evidence to establish that he actually experienced the employment incident at the time, place, and in the manner alleged. Second, the employee must submit medical evidence to establish that the employment incident caused a personal injury.5

Rationalized medical opinion evidence is generally required to establish causal relationship. The opinion of the physician must be based on a complete factual and medical background, 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.6

ANALYSIS

The Board finds that the claimed work incident occurred as alleged. However, the medical evidence is insufficient to establish that the employment incident on March 9, 2013 caused a right shoulder condition or carpal tunnel syndrome.

In his November 4, 2013 report, Dr. Geer noted that appellant was at work sweeping mail from a bin into trays when he began to feel pain. He advised that appellant had mild carpal tunnel syndrome and opined that appellant’s condition “could certainly have been caused by repetitive motion” at work. Although Dr. Geer offers an opinion on causal relationship, his opinion is speculative in nature and does not provide any medical rationale explaining how the established work incident caused carpal tunnel syndrome.7 He states that appellant’s injury could have been the result of repetitive work activities but he does not explain how the March 9,

2
J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 57 (1968).
3
R.C., 59 ECAB 427 (2008).
4
Id.; Elaine Pendleton, 40 ECAB 1143, 1145 (1989).
5
T.H., 59 ECAB 388 (2008).
6
I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989).
7
Cecelia M. Corley, 56 ECAB 662 (2005) (a physician’s opinion that is speculative or equivocal is of little probative value).

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2013 work incident caused any diagnosed condition.8 Dr. Geer also did not indicate awareness that appellant initially only claimed a right shoulder injury, nor did he otherwise explain how the March 9, 2013 incident caused or aggravated carpal tunnel syndrome.9

Appellant submitted several reports from Dr. Blum diagnosing shoulder pain. In an April 19, 2013 report, Dr. Blum stated that appellant presented with a 10-day history of moderate aching pain in the right shoulder that was associated with using a machine and lifting a tray of mail above his shoulder at work. In a June 10, 2013 report, as well as in his work status reports, he noted appellant’s status but did not offer a diagnosis, other than pain, or address causal relationship. The Board finds that Dr. Blum failed to provide a specific medical diagnosis of appellant’s right shoulder injury. Dr. Blum’s diagnosis of right shoulder pain, without any explanation of the shoulder condition causing the pain, is a description of a symptom rather than a firm diagnosis of a compensable medical condition.10 He did not otherwise provide medical rationale explaining how the March 9, 2013 work incident caused a particular condition. Instead, Dr. Blum’s reports generally note no abnormal right shoulder findings. Thus, his reports are insufficient to discharge appellant’s burden of proof.

Dr. Piggott’s March 9, 2012 report notes appellant’s work status but did not specifically address whether appellant had a diagnosed condition causally related to his employment. This report is insufficient to establish the claim.11

In an unsigned March 9, 2012 attending physician’s report (CA-16), an unidentified provider noted that appellant had right shoulder weakness and indicated that appellant’s injury was caused by factors of his employment by checking the box marked “yes.” However, the Board has held that unsigned medical reports are of no probative value when their authorship cannot be determined, as it cannot be discerned whether a physician signed the reports.12 Moreover, the March 9, 2012 report fails in providing a diagnosis. Appellant also submitted several physical therapy reports. However, records from a physical therapist do not constitute competent medical opinion in support of causal relation. A physical therapist is not a physician

8
To the extent that Dr. Geer asserts that the diagnosed condition was due to repetitive activities that occurred over more than one day, rather than during a single workday or shift, this would be more consistent with a claim for occupational disease than one for traumatic injury. See 20 C.F.R. § 10.5(q) & (ee). 9 See Vernon R. Stewart, 5 ECAB 276, 280 (1953) (where the Board held that medical opinions based on histories that do not adequately reflect the basic facts are of little probative value in establishing a claim). 10 The Board has consistently held that pain is a symptom, rather than a compensable medical diagnosis. C.F., Docket No. 08-1102 (issued October 10, 2008).
11
S.E., Docket No. 08-2214 (issued May 6, 2009) (medical evidence that does not offer any opinion regarding the cause of an employee’s condition is of limited probative value on the issue of causal relationship). 12 See Merton J. Sills, 39 ECAB 572, 575 (1988). Furthermore, even if the report were signed by a physician, the Board has held that an opinion on causal relationship that consists only of a physician checking “yes” to a medical form question on causal relationship is of little probative value. See Deborah L. Beatty, 54 ECAB 334 (2003) (the checking of a box yes in a form report, without additional explanation or rationale, is insufficient to establish causal relationship).

5 as defined under FECA.13 Thus, records from physical therapists are insufficient to establish the claim.14

Consequently, appellant has submitted insufficient medical evidence to establish his claim. As noted, causal relationship is a medical question that must be established by probative medical opinion from a physician.15 The physician must accurately describe appellant’s work duties and medically explain the pathophysiological process by which these duties would have caused or aggravated his condition.16 Because appellant has not provided such medical opinion evidence in this case, he has failed to meet his burden of proof.

Appellant may submit new evidence or argument as part of a formal written request for reconsideration to OWCP within one year of this merit decision, pursuant to 5 U.S.C. § 8128(a) and 20 C.F.R. §§ 10.605 through 10.607.

CONCLUSION

The Board finds that appellant did not establish that he sustained an injury in the performance of duty.

13
A.C., Docket No. 08-1453 (issued November 18, 2008). Under FECA, a “physician” includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by State law. 5 U.S.C. § 8101(2). See also Charley V.B. Harley, 2 ECAB 208, 211 (1949) (where the Board held that medical opinion, in general, can only be given by a qualified physician). 14 Allen C. Hundley, 53 ECAB 551 (2002); Lyle E. Dayberry, 9 ECAB 369 (1998).
15
See supra note 6.
16
Solomon Polen, 51 ECAB 341 (2000) (rationalized medical evidence must relate specific employment factors identified by the claimant to the claimant’s condition, with stated reasons by a physician). See also S.T., Docket No. 11-237 (issued September 9, 2011).

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 ORDER

IT IS HEREBY ORDERED THAT the April 16, 2014 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: November 25, 2014
Washington, DC

Christopher J. Godfrey, Chief Judge
Employees’ Compensation Appeals Board

Patricia Howard Fitzgerald, Judge
Employees’ Compensation Appeals Board

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

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