A.G. and U.S. Postal Service, Post Office, Tampa, FL (Board decision, December 9, 2015)

ECAB final decision. The Board affirmed OWCP’s May 15, 2015 denial of A.G.’s right shoulder injury claim. A party may petition the Board for reconsideration within 30 days of issuance unless this decision specifies another period, under 20 C.F.R. § 501.7(a).

Plain-English summary

A.G., a Postal Service mail handler, reported shoulder pain while tightening straps on equipment in a trailer. The Board found that physicians’ reports did not explain how the April 9, 2014 incident caused or aggravated a diagnosed condition. Some reports described pain beginning weeks or months earlier, while others only checked a box indicating work causation. The Board affirmed the claim denial because the medical evidence did not adequately address the claimed incident or its causal link to the shoulder condition.

Decision snapshot

• Authority: Federal Employees’ Compensation Act, 5 U.S.C. § 8101 et seq.
• Outcome: May 15, 2015 shoulder injury denial affirmed.
• Key point: Inconsistent injury histories and unexplained causation statements did not establish a work related shoulder injury.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
A.G., Appellant
)
)
and ) Docket No. 15-1766
) Issued: December 9, 2015
U.S. POSTAL SERVICE, POST OFFICE,
)
Tampa, 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:
CHRISTOPHER J. GODFREY, Chief Judge
COLLEEN DUFFY KIKO, Judge
VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On August 17, 2015 appellant, through counsel, filed a timely appeal from a May 15, 2015 merit decision of the Office of Workers’ Compensation Programs (OWCP). 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 to establish an injury causally related to an April 9, 2014 employment incident.

FACTUAL HISTORY

On April 10, 2014 appellant, then a 54-year-old mail handler, filed a traumatic injury claim (Form CA-1) alleging that he sustained a right shoulder injury on April 9, 2014 when he

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5 U.S.C. § 8101 et seq. experienced intense right shoulder pain while placing the upper straps to equipment on a trailer. Appellant did not immediately stop work, but was placed on light duty.

By statement dated April 10, 2014, appellant advised that while tightening straps on double stacked crab cages he felt immediate pain in his right shoulder. He noted that he informed his supervisor that day and sought medical treatment the following day.

In an April 10, 2014 emergency room report, Dr. Frederick Yonteck, Board-certified in emergency medicine, noted that appellant had an onset of right shoulder pain three weeks prior. He attributed the injury to lifting at work. On examination Dr. Yonteck reported tenderness over the deltoid and acromioclavicular (AC) joint. In an accompanying April 10, 2014 diagnostic report, Dr. Cory Rizzardi, Board-certified in diagnostic radiology, advised that an x-ray of the right shoulder revealed no fracture and three-and-a-half millimeter elevation inferior distal clavicular surface relative to the inferior acromion, probably within normal limits.

On April 17, 2014 Dr. Michael Garcia, a Board-certified orthopedic surgeon, advised that appellant had been experiencing right shoulder pain for the past three months. He noted that appellant experienced the same symptoms while working at the employing establishment 15 years prior and was diagnosed with rotator cuff tendinitis. Examination of the right shoulder revealed pain with palpation over the bicipital groove and over the lateral humeral head, 4/5 muscle strength, 0 to 160 degrees of forward flexion, 0 to 160 degrees of abduction, and 0 to 45 degrees of external rotation and internal rotation to the level of L1. Dr. Garcia assessed right rotator cuff tendinitis and gave appellant a corticosteroid injection into the right shoulder joint subacromial space. In an accompanying Florida Workers’ Compensation Treatment Form, he checked a box to indicate that appellant’s injury was work related.

Dr. Garcia, in a May 29, 2014 report, advised that appellant had a workers’ compensation claim for right rotator cuff tendinitis. He noted that appellant related that his right shoulder was feeling better and that he stopped work six weeks prior. Examination of the right shoulder revealed minimal tenderness to palpation about the shoulder over the greater tuberosity, good shoulder range of motion and strength, and positive impingement maneuvers. Dr. Garcia recommended that appellant undergo physical therapy. Several physical therapy reports were submitted.

By letter dated July 25, 2014, OWCP advised appellant of the type of evidence needed to establish his claim.

Appellant thereafter provided a July 17, 2014 report from Dr. Garcia who advised that appellant’s symptoms improved, but he was still having difficulty with overhead activity and over the shoulder work. On examination Dr. Garcia noted 5/5 strength in the rotator cuff, normal range of motion, good strength, and positive impingement signs. He noted that appellant would be treated with a corticosteroid injection that day and that he would continue light duty.

By decision dated September 4, 2014, OWCP denied appellant’s claim because medical evidence was insufficient to establish that he sustained an injury causally related to the accepted work event.

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 In a September 30, 2014 report, Dr. John Tedesco, a Board-certified osteopath specializing in family medicine, advised that appellant injured his shoulder at work in April. He noted that he treated appellant on April 28, 2014 for the injury. Dr. Tedesco explained that appellant was injured as a result of lifting and attaching straps which caused sudden pain in the right shoulder. Examination of the right shoulder revealed near full range of motion, mild tenderness on internal and external rotation of the humerus, and no point tenderness. Dr. Tedesco assessed tendinitis and joint pain in the shoulder region. In an accompanying September 30, 2014 Florida Workers’ Compensation Treatment Form, he checked a box to indicate that appellant’s injury was work related. Dr. Tedesco also indicated that appellant was able to return to work with restrictions. He limited pushing and pulling to 10 pounds and restricted overhead reaching.

In an October 30, 2014 report, Dr. Robert Reppy, an osteopath specializing in preventative medicine, advised that appellant complained of right shoulder pain. He noted that, on April 9, 2014, appellant was on a loading dock strapping equipment onto a trailer when he felt sudden pain and burning as he reached overhead to tighten the straps. Dr. Reppy advised that, in the “remote past,” appellant had an episode of tendinitis due to repetitive right arm motions but “all the symptoms disappeared with cessation of the repetitive task and rest” with the arm being “symptom-free for many years before the date of the current injury.” Right shoulder examination revealed tenderness and pain with abduction at the extreme of its range. Dr. Reppy advised that appellant’s previous health care provider did not complete a diagnostic work-up and simply assumed his condition was tendinitis. He ordered right shoulder magnetic resonance imaging (MRI) scans and diagnosed right shoulder strain. Dr. Reppy opined that appellant likely had a right rotator cuff tear, but noted that imaging results were needed to make a firm diagnosis.

In a January 8, 2015 report, Dr. Reppy advised that appellant’s April 9, 2014 date of injury reflected when he filed his claim as opposed to when his pain first appeared, which was three months earlier. He diagnosed full-thickness tear of the supraspinatus tendon as confirmed by a December 12, 2014 MRI scan.

On February 11, 2015 appellant requested reconsideration.

By decision dated May 15, 2015, OWCP denied modification of the denial of appellant’s claim finding that the medical evidence was insufficient to establish causation between the work incident and diagnosed condition.

LEGAL PRECEDENT

An employee seeking compensation under FECA has the burden of establishing the essential elements of his or her claim by the weight of reliable, probative, and substantial evidence,2 including that he or she is an “employee” within the meaning of FECA and that he or she filed his or her claim within the applicable time limitation.3 The employee must also

2
J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 57 (1968).
3
R.C., 59 ECAB 427 (2008).

3 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

There is no dispute that on April 9, 2014 the alleged incident with the equipment straps occurred. Therefore, the Board affirms the finding that the first component of fact of injury is established. However, the medical evidence is insufficient to establish that the employment incident on April 9, 2014 caused or aggravated appellant’s diagnosed condition.

In his October 30, 2014 report, Dr. Reppy, advised that appellant was strapping equipment onto a trailer when he felt sudden pain and burning as he reached overhead to tighten the straps. He indicated that appellant had previous right shoulder tendinitis, but had been symptom free for years. In his January 8, 2015 report, Dr. Reppy clarified that appellant’s April 9, 2014 date of injury reflected when he filed his claim and not when the pain first appeared, which was three months earlier. Although these reports provide some support for causal relationship, they are insufficient to discharge appellant’s burden of proof because they do not offer medical rationale in support of an opinion on causal relationship. The need for rationale is particularly important where, initially, Dr. Reppy indicated that appellant’s previous right shoulder condition had been asymptomatic for years, but in his most recent report acknowledged that appellant had symptoms three months before the date of injury. He did not address how his changed understanding of appellant’s symptom history affected his opinion on causal relationship since his initial report was erroneously premised on appellant’s condition being dormant for years.7

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
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).

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 In his September 30, 2014 report, Dr. Tedesco advised that appellant injured his shoulder at work in April. He noted that he treated appellant on April 28, 2014 and that appellant related that his injury was caused by lifting and attaching straps. Although Dr. Tedesco attributed appellant’s injury to lifting and attaching straps, he did not provide medical rationale explaining how this could have caused or aggravated the diagnosed condition. The Board has long held that medical opinions not containing rationale on causal relation are of diminished probative value and are generally insufficient to meet appellant’s burden of proof.8 In his accompanying Florida Workers’ Compensation Treatment Form, Dr. Tedesco checked a box to indicate that appellant’s injury was work related. However, the Board has held that an opinion on causal relationship that consists only of a physician checking a box marked “yes” to a medical form question is of little probative value.9

In his April 10, 2014 hospital report, Dr. Yonteck attributed appellant’s injury to lifting at work three weeks prior. Appellant indicated that he was injured on April 9, 2014. However, Dr. Yonteck notes that the injury occurred three weeks prior to his April 10, 2014 visit. This report is insufficient to discharge appellant’s burden of proof as it does not reflect the history as provided by appellant.10

In his April 17, 2014 report, Dr. Garcia advised that appellant had been experiencing right shoulder pain for the past three months. He noted that appellant experienced the same symptoms while working at the employing establishment 15 years prior and was diagnosed with rotator cuff tendinitis. This report is insufficient to discharge appellant’s burden of proof because it does not reference the April 9, 2014 work incident alleged by appellant. In an April 17, 2014 Florida Workers’ Compensation Treatment Form, Dr. Garcia indicated that appellant’s injury was work related by checking a box. As stated, an opinion on causal relationship that consists only of a physician checking “yes” is of little probative value.11 Other reports by Dr. Garcia are also insufficient to discharge appellant’s burden of proof as they do not provide an opinion on causal relationship.

The Board therefore finds that appellant has submitted insufficient medical evidence to establish his claim.12

Appellant may submit new evidence or argument with a 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.

8
Carolyn F. Allen, 47 ECAB 240 (1995).
9
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). 10 See supra note 7.
11
Supra note 9.
12
Jennifer Atkerson, 55 ECAB 317 (2004).

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 CONCLUSION

The Board finds that appellant has not met his burden of proof to establish an injury causally related to an April 9, 2014 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the May 15, 2015 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: December 9, 2015
Washington, DC

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

Colleen Duffy Kiko, Judge
Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge Employees’ Compensation Appeals Board

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