B.R. and Social Security Administration, Suisan City, CA (Board decision, April 25, 2016)

ECAB final decision. The Board affirmed OWCP’s September 4, 2015 denial of B.R.’s claim for a wrist and arm injury. 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

B.R., a Social Security service representative, reported hurting her left wrist and arm while moving a desk at work in October 2014. OWCP accepted that the incident happened but found the medical evidence did not establish an injury caused by it. The Board noted that her physician’s reports identified a different injury date and discussed preexisting wrist problems without explaining how the October incident caused or aggravated a diagnosed condition. It affirmed the denial because the reports lacked an accurate history and a reasoned causal opinion.

Decision snapshot

• Authority: FECA traumatic injury and medical causation requirements; 20 C.F.R. § 10.5(ee).
• Outcome: September 4, 2015 claim denial affirmed.
• Key point: An accepted workplace incident still required medical evidence explaining its connection to a diagnosed injury.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

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B.R., Appellant
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and ) Docket No. 16-0456
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Issued: April 25, 2016
SOCIAL SECURITY ADMINISTRATION,
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Suisan City, CA, Employer
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___________ )

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
ALEC J. KOROMILAS, Alternate Judge
VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On January 11, 2016 appellant, through counsel, filed a timely appeal of a September 4, 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 met her burden of proof to establish a traumatic injury causally related to an October 27, 2014 employment incident.

FACTUAL HISTORY

On October 27, 2014 appellant, then a 30-year-old service representative, filed a traumatic injury claim (Form CA-1) alleging that on October 27, 2014 at 7:45 a.m. she injured

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5 U.S.C. § 8101 et seq. her left wrist and arm while moving her desk.2 She stated that at that time she was wearing a left wrist brace and, as she tried to pull the name tag off her desk, some plastic snapped and her wrist was pulled and twisted. Appellant advised that her wrist was severely hurting. She stopped work on October 28, 2014. The employing establishment noted that the doctor placed her off work for 45 days.

In a November 13, 2014 letter, OWCP advised appellant that additional factual and medical evidence was needed. It informed appellant of the type of evidence needed to support her claim and requested that she submit such evidence within 30 days.

Appellant provided several reports from Dr. Robert A. Gomez, a Board-certified orthopedic surgeon. In a November 12, 2014 report, Dr. Gomez noted that appellant presented with left shoulder, elbow, and wrist injuries that occurred on May 7, 2013 when she was moving office material from her old desk to a new desk and injured her left wrist trying to remove the name plate from her cubicle. He advised that she felt a pop and had immediate pain but was able to finish the workday. Appellant related that the next morning she awoke to find the left wrist and hand swollen. She saw an orthopedist the next day, was put in a thumb splint, and received follow-up care. He noted that she had a previous left wrist injection without benefit and was off work since her injury. The physician noted that she was complaining of left wrist, elbow, and shoulder pain and presented wearing a short-arm thumb brace with a forearm band for her lateral epicondylitis. Appellant denied any other history of previous injury or similar symptoms of the left wrist. She did have a prior history of right wrist first dorsal compartment release. The physician explained that her left wrist pain awakened her on a nightly basis and advised that she had difficulty with activities of daily living. Dr. Gomez indicated she took medication, and had a left wrist and shoulder injection, which did not help, although her current wrist brace helped. Left wrist findings included tenderness over the dorsal compartment, the lateral epicondyle, and the radial tunnel. She had mild pain with wrist extension against resistance and no pain with wrist flexion against resistance. The physician also determined that the left shoulder was tender over the anterior aspect of the acromion and the biceps tendon. Dr. Gomez diagnosed left wrist de Quervain’s tenosynovitis, left elbow lateral epicondylitis, radial tunnel syndrome, and left shoulder impingement syndrome with associated biceps tendinitis. He advised that a previous physician performed a left wrist first dorsal compartment injection without benefit. The physician recommended a first dorsal compartment release at the wrist. He also indicated that appellant was advised to stop wearing the forearm band as it typically exacerbated radial tunnel syndrome. Regarding the elbow, he recommended extensor carpi radialis brevis (ECRB) debridement and radial tunnel release. Dr. Gomez also diagnosed left shoulder impingement syndrome with associated biceps tendinitis and explained that she would eventually require an arthroscopic subacromial decompression and biceps tendon release versus resection. He advised that authorization for these procedures would be requested.

In a November 24, 2014 report, Dr. Gomez noted that appellant was totally disabled for the period from October 28 to December 16, 2014. He indicated he would be requesting authorization for first dorsal compartment release at the wrist, ECRB debridement, and radial

2
The original claim form indicated a September 27, 2014 date of injury. However, this was amended to October 27, 2014.

2 tunnel release of the left elbow. The physician opined that her left shoulder and wrist injuries occurred on May 7, 2013 when she was moving office material from her old desk to a new desk. Dr. Gomez explained that she injured her left wrist trying to remove the name plate from her cubicle, felt a pop and had immediate pain. He diagnosed left wrist de Quervain’s tenosynovitis, left elbow lateral epicondylitis, radial tunnel syndrome, biceps tendinitis, and coracoids impingement.

By decision dated December 12, 2014, OWCP denied appellant’s claim because she did not establish an injury as alleged as the factual component had not been met. It noted that appellant did not respond to the request for factual information. OWCP also noted that she had indicated that she was wearing a left wrist brace and was claiming a left wrist injury and that she did not explain why she was working prior to her start time. OWCP further found that the medical evidence was insufficient as the date of injury was referred to as May 7, 2013 and not October 27, 2014 as indicated in her claim. Appellant was advised that if she was pursuing an injury due to an incident of May 7, 2013,3 she should pursue the matter under that claim No. xxxxxx664.4

On December 30, 2014 OWCP received appellant’s request for a telephonic hearing before an OWCP hearing representative, which was held on July 14, 2015. She reiterated that the date of injury was October 27, 2014.

In a December 15, 2014 treatment note, Dr. Gomez advised that appellant returned for reevaluation of her left upper extremity. He indicated that they were awaiting authorization and she continued to have severe left upper extremity pain with daily use and was unable to tolerate any anti-inflammatory medications. The physician advised that she took Tylenol for pain and used ice and wrist braces. He noted that the current magnetic resonance imaging (MRI) scans of the left wrist were unremarkable as there was a small subchondral cyst on the lunate. Dr. Gomez found tendinosis of the common extensor region on the left elbow and advised that she remain off work. OWCP also received copies of prior reports.

In a January 7, 2015 treatment note, Dr. Gomez indicated that appellant returned for re- evaluation. He repeated his previous diagnoses and noted that her claim was denied. The physician indicated that he would try to proceed with surgery through her regular insurance.

On January 8, 2015 OWCP received appellant’s questionnaire, which was dated December 29, 2014. She noted that she was told by management that she had a new injury. She also indicated that her work start time was flexible from 7:00 a.m. to 9:00 a.m. and she was working at the time of her injury.

In a February 13, 2015 duty status report (Form CA-17), Dr. Gomez release appellant to work with restrictions to include no use of the left hand.

3
The Board notes that, although OWCP actually included a second date of May 7, 2014, this appears to be a typographical error as it initially referred to May 7, 2013. 4 Claim number xxxxxx664 is not before the Board on the present appeal.

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 By decision dated September 4, 2015, an OWCP hearing representative affirmed the December 12, 2014 decision. She found that the factual component of appellant’s claim was accepted. However, the hearing representative further found that the medical evidence was insufficient as there was no rationale to support causal relationship.

LEGAL PRECEDENT

An employee seeking benefits under FECA has the burden of proof to establish the essential elements of his or her claim, including the fact that the individual is an “employee of the United States” within the meaning of FECA, that the claim was timely filed within the applicable time limitation period of FECA,5 and that an injury was sustained in the performance of duty.6 These are the essential elements of each compensation claim, regardless of whether the claim is predicated upon a traumatic injury or an occupational disease.7

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.8 Second, the employee must submit sufficient evidence, generally only in the form of medical evidence, to establish that the employment incident caused a personal injury.9

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.10

ANALYSIS

In this case, OWCP has accepted that on October 27, 2014 the claimed incident occurred as alleged. Therefore, the Board finds that the first component of fact of injury, the claimed incident, is established.

However, with regard to the medical evidence, the Board finds that it is insufficiently rationalized to establish the second component of fact of injury, that the employment incident caused an injury. The medical evidence contains no reasoned explanation of how the specific

5
Joe D. Cameron, 41 ECAB 153 (1989).
6
James E. Chadden, Sr., 40 ECAB 312 (1988).
7
Delores C. Ellyett, 41 ECAB 992 (1990).
8
Julie B. Hawkins, 38 ECAB 393, 396 (1987).
9
Id. For a definition of the term “traumatic injury,” see 20 C.F.R. § 10.5(ee).
10
I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989).

4 employment incident on October 27, 2014 caused or aggravated an injury.11 The Board notes that this is particularly important in light of the reference to pre-existing conditions to include the fact that she was already wearing a left wrist brace at the time of the incident.

Appellant submitted several reports from Dr. Gomez. However, these reports are of limited value as they contain an inaccurate history of injury. The Board notes that appellant clearly indicated that the date of injury was October 27, 2014. However, Dr. Gomez referred to the injury date as May 7, 2013 in both his November 12 and 24, 2014 reports. He also referenced preexisting conditions and her prior treatment. It is well established that medical reports must be based on a complete and accurate factual and medical background, and medical opinions based on an incomplete or inaccurate history are of little probative value.12 His subsequent reports contained diagnoses and requests for surgeries, but there was no accurate history of injury provided. He did not offer any opinion with regard to a work injury occurring on October 27, 2014 involving the movement of her desk.

Other reports are also of limited probative value on the relevant issue as they do not contain an accurate history of injury or an opinion on causal relationship.

Because the medical reports submitted by appellant do not address how the October 27, 2014 activities at work caused or aggravated a left wrist or arm condition, these reports are of limited probative value13 and are insufficient to establish that the October 27, 2014 employment incident caused or aggravated a specific injury. Therefore, appellant has not met her burden of proof.

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.

CONCLUSION

The Board finds that appellant did not meet her burden of proof to establish a traumatic injury causally to an October 27, 2014 employment incident.

11
See George Randolph Taylor, 6 ECAB 986, 988 (1954) (where the Board found that a medical opinion not fortified by medical rationale is of little probative value). 12 Douglas M. McQuaid, 52 ECAB 382 (2001).
13
See Linda I. Sprague, 48 ECAB 386, 389-90 (1997).

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 ORDER

IT IS HEREBY ORDERED THAT the September 4, 2015 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: April 25, 2016
Washington, DC

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

Alec J. Koromilas, Alternate Judge
Employees’ Compensation Appeals Board

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

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