Z.T. and U.S. Postal Service, Post Office, Beachwood, OH (Board decision, June 6, 2016)

ECAB final decision. The Board affirmed OWCP’s December 23, 2015 denial of the foot 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). FECA compensation decisions are generally not subject to court review under 5 U.S.C. § 8128(b).

Plain-English summary

Z.T., a postal carrier, reported injuring her right foot while walking up stairs at work. The Board accepted that the July 2, 2015 event occurred. It found that the medical evidence did not adequately connect a diagnosed condition to that event. The Board affirmed the claim denial.

Decision snapshot

• Authority: 5 U.S.C. § 8101 et seq..
• Outcome: December 23, 2015 denial affirmed.
• Key point: An accepted workplace event still required reasoned medical causation evidence.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
Z.T., Appellant
)
)
and ) Docket No. 16-0690
) Issued: June 6, 2016
U.S. POSTAL SERVICE, POST OFFICE,
)
Beachwood, OH, 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
PATRICIA H. FITZGERALD, Deputy Chief Judge VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On February 23, 2016 appellant, through counsel, filed a timely appeal from a December 23, 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 a July 2, 2015 employment incident.

FACTUAL HISTORY

On July 13, 2015 appellant, then a 25-year-old mail carrier, filed a traumatic injury claim (Form CA-1) alleging a right foot injury while walking up stairs on July 2, 2015. She stopped work that day.

1
5 U.S.C. § 8101 et seq.
 In a July 13, 2015 disability status report, Dr. Jeanna Fascione, a podiatrist, advised that appellant was unable to work until she was reevaluated in three weeks.

By letter dated July 16, 2015, OWCP advised appellant of the type of evidence needed to establish her claim.

The employing establishment controverted appellant’s claim in a July 22, 2015 letter.

In an August 3, 2015 attending physician’s report (Form CA-20), Dr. Fascione advised that appellant experienced sharp right foot pain in June 2015 after increased walking and stair use. She assessed right tarsal metatarsal dislocation and advised that appellant was immobilized and being treated with rest and anti-inflammatory medication. Dr. Fascione checked the box marked “yes” to indicate that the diagnosed condition was caused or aggravated by the employment duties.

In an August 3, 2015 duty status report (Form CA-17), Dr. Fascione advised that appellant’s injury was due to overuse including walking and climbing stairs. She assessed right metatarsal dislocation and noted that appellant was unable to return to work until evaluated at her next visit.

By decision dated August 25, 2015, OWCP denied appellant’s claim, finding that the medical evidence of record was insufficient to establish that the diagnosed medical condition was causally related to the accepted work event.

In a July 13, 2015 report, Dr. Fascione advised that appellant had a new injury and was following up from an old injury. Appellant reported increased walking activities at work and advised that her date of injury was June 2015. Dr. Fascione noted that appellant previously underwent an open reduction and internal fixation (ORIF) of the right foot several years ago, but her pain was now in a new location. Examination revealed an antalgic gait, 5/5 ankle muscle strength, intact sensation, decreased ankle joint dorsiflexion with the knees extended, decreased medial longitudinal arch in weight bearing stance, and pain on palpation to medial tarsal metatarsal, medial and dorsal medial right foot. There were no open lesions, macerations, ecchymosis, or erythema. Dr. Fascione diagnosed right tarsal metatarsal dislocation. She noted that an x-ray revealed a right flack sign which was consistent with right lisfranc fracture dislocation. In a July 23, 2014 report, Dr. Fascione assessed bilateral plantar fasciitis.

On September 25, 2015 appellant requested reconsideration.

In a September 14, 2015 report, Dr. Fascione advised that appellant complained of right midfoot pain. She noted that appellant was immobilized with a controlled ankle movement (CAM) walker boot, which brought her partial relief. Dr. Fascione reiterated findings on examination from her earlier report and diagnosed right tarsal metatarsal dislocation. She indicated that appellant’s claim was denied due to a discrepancy with the date of injury, but opined that from a clinical standpoint her injury correlated with her reported work tasks.

Dr. Fascione, in a September 16, 2015 report, advised that appellant sustained an overuse injury causally related to walking and stair use. She opined that walking for this length of time would absolutely contribute to an overuse injury. Dr. Fascione noted that appellant had

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“progressive aggravation with an onset of end [June 2015] according to [her] documentation, and
[appellant] had stepped in the same site while on the stairs close to this time frame according to her reported date of injury.” In an October 14, 2015 report, she advised that appellant reported some improvement of her right midfoot injury sustained at work, but noted that her pain was still aggravated with weight bearing activities. In an October 28, 2015 report, Dr. Fascione advised that appellant’s right midfoot injury, sustained at work, was reaggravated and was only improved by her CAM boot. She noted that appellant understood that surgery could possibly be warranted if conservative care failed. Dr. Fascione advised that appellant was able to return to light duty if tolerated. On December 2, 2015 she advised that appellant related up to 30 percent improvement. Dr. Fascione noted that she began experiencing burning in her heels, but related no new bruising or swelling. She advised that appellant denied reinjury, but worried that her plantar fasciitis was returning.

By decision dated December 23, 2015, OWCP denied modification of its previous decision.

LEGAL PRECEDENT

An employee seeking compensation under FECA has the burden of proof to establish 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 the individual filed the claim within the applicable time limitation.3 The employee must also establish that she sustained an injury in the performance of duty as alleged and that her 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

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).

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 ANALYSIS

Appellant claimed that she sustained a right foot injury as a result of walking up stairs on July 2, 2015. There is no dispute that the incident occurred as alleged. However, the Board finds that the medical evidence of record is insufficient to establish that the medical condition was causally related to the accepted work incident.

In her September 14, 2015 report, Dr. Fascione advised that appellant complained of right midfoot pain. She indicated that appellant’s claim was denied due to a discrepancy with the date of injury, but opined that from a clinical standpoint appellant’s injury correlated with her reported work tasks. Although Dr. Fascione opined that the injury correlated with the reported work tasks, she does not explain how these tasks caused right tarsal metatarsal dislocation. 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.7

Dr. Fascione, in a September 16, 2015 report, opined that appellant’s injury was causally related to walking and stair use. She indicated that walking for this length of time would absolutely contribute to an overuse injury and that appellant’s symptoms began at the end of June 2015. While Dr. Fascione attributed her diagnosed condition to walking and stair use, she does not explain how these duties resulted in her diagnosed condition. Furthermore, she related appellant’s condition to her general duties as a mail carrier as opposed to a specific injury on July 2, 2015 as indicated by appellant in her notice of traumatic injury claim form. The Board has held that medical opinions based on an inaccurate or incomplete history have diminished probative value.8 As a result, this report is insufficient to discharge appellant’s burden of proof.

In her July 13, 2015 report, Dr. Fascione advised that appellant had a new injury and was following up from an old injury. She noted that appellant reported increased walking activities at work and advised that her date of injury was June 2015. Dr. Fascione simply repeated the history as related by appellant. The Board has held that a physician’s opinion regarding causal relationship that is primarily based on appellant’s own representations rather than on objective medical findings is of limited probative value.9

In her October 14 and 28, 2015 reports, Dr. Fascione, advised that appellant’s right midfoot injury was sustained at work. The Board has found that the mere fact that a condition manifests itself or is worsened during an employment period does not raise an inference of causal relationship between the two.10 Therefore, these reports are insufficient to discharge appellant’s burden of proof. In an August 3, 2015 attending physician’s report (Form CA-20), Dr. Fascione checked a box marked “yes” to indicate that the diagnosed condition was caused or aggravated by the employment duties. The Board has held that an opinion on causal relationship

7
Carolyn F. Allen, 47 ECAB 240 (1995).
8
L.G., Docket No. 09-1692 (issued August 11, 2010); M.W., 57 ECAB 710 (2006); James R. Taylor, 56 ECAB 537 (2005).
9
C.M., Docket No. 14-88 (issued April 18, 2014).
10
Patricia Bolleter, 40 ECAB 373 (1988).

4 that consists only of a physician checking “yes” to a medical form question on whether the claimant’s condition was related to the history given is of little probative value.11

Other reports by Dr. Fascione, including disability status and duty status reports are insufficient to discharge appellant’s burden of proof as they did not address causal relationship.12

Consequently, appellant has submitted insufficient medical evidence to establish her traumatic injury claim.13 As noted, causal relationship is a medical question that must be established by probative medical opinion from a physician.14 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.15 The need for medical reasoning or rationale is particularly important given the fact that medical evidence of record indicates that appellant had a preexisting right foot condition.

Appellant may submit new evidence or argument as part of 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 an injury causally related to a July 2, 2015 employment incident.

11
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). 12 See Jaja K. Asaramo, 55 ECAB 200 (2004) (medical evidence that does not offer an opinion regarding the cause of an employee’s condition is of limited probative value on the issue of causal relationship). 13 OWCP regulations define an occupational disease or illness as a condition produced by the work environment over a period longer than a single workday or shift. 20 C.F.R. § 10.5(q). The Board notes that although the medical evidence of record suggests that appellant’s injury occurred due to walking and stair use over a period of time, the issue of whether appellant sustained an occupational disease is not currently before the Board. 14 See supra note 6.
15
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 December 23, 2015 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: June 6, 2016
Washington, DC

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

Patricia H. Fitzgerald, Deputy Chief Judge Employees’ Compensation Appeals Board

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

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