M.S. and U.S. Postal Service, Post Office, Portland, ME (Board decision, December 7, 2016)

ECAB final decision. The Board affirmed OWCP’s May 13, 2016 denial of the 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

A postal mail clerk tripped on plastic strapping at work and claimed left ankle and foot conditions. OWCP accepted that the incident occurred, but the Board found that a physician’s checked box and other reports did not explain how the incident caused the diagnosed conditions. Imaging reports identified findings without addressing causation. The Board affirmed the claim denial.

Decision snapshot

• Authority: FECA traumatic injury and medical causation.
• Outcome: May 13, 2016 injury claim denial affirmed.
• Key point: The medical evidence lacked a reasoned explanation linking the incident to the diagnoses.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
M.S., Appellant
)
)
and ) Docket No. 16-1362
) Issued: December 7, 2016
U.S. POSTAL SERVICE, POST OFFICE,
)
Portland, ME, Employer
)
__________ )

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

DECISION AND ORDER

Before:
PATRICIA H. FITZGERALD, Deputy Chief Judge ALEC J. KOROMILAS, Alternate Judge
VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On June 22, 2016 appellant filed a timely appeal from a May 13, 2016 merit decision of the Office of Workers’ Compensation Programs1 (OWCP). Pursuant to the Federal Employees’ Compensation Act2 (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 left ankle and foot conditions causally related to the accepted March 21, 2016 employment incident.

1
The Board notes that appellant submitted additional evidence after OWCP rendered its May 13, 2016 decision.
The Board’s jurisdiction, however, is limited to reviewing the evidence that was before OWCP at the time of its final decision and; therefore, this additional evidence cannot be considered on appeal. 20 C.F.R. § 501.2(c)(1); Dennis E. Maddy, 47 ECAB 259 (1995); James C. Campbell, 5 ECAB 35, 36 n.2 (1952). 2 5 U.S.C. § 8101 et seq.
 FACTUAL HISTORY

On March 30, 2016 appellant, then a 50-year-old mail clerk, filed a traumatic injury claim (Form CA-1) alleging that on March 21, 2016 she tripped on a yellow piece of strapping which wrapped around her left ankle. The following day she fell in the parking lot due to her weakened ankle, causing a sprain. Appellant notified her supervisor on March 23, 2016 and stopped work on March 24, 2016.

In an accompanying narrative statement, appellant reported that in the morning on March 21, 2016, she was performing expediting duties on the platform when she felt herself about to fall. She caught herself and found a yellow plastic ring of strapping wrapped around her left ankle. Appellant finished her shift despite pain. She noted that her foot had been painful two months prior, but she thought it had improved until the March 21, 2016 incident. Appellant further explained that the following day she returned to work and after finishing her shift, her left ankle and heel felt weak, causing her to fall to the ground. She reported that the swelling and pain in her ankle and heel worsened, causing her to seek medical treatment.

By letter dated March 30, 2016, the employing establishment controverted the claim.

In a March 30, 2016 narrative statement, appellant’s supervisor reported that on March 21, 2016 she informed him that while she performed expediting duties on the platform, she tripped over a yellow piece of strapping. Appellant returned to work on the following day and worked a full shift. On March 23, 2016 she notified him that on March 22, 2016 she had “punched out” at the end of the day but, while walking to her car, her ankle gave out, causing her to fall to the ground. Appellant’s supervisor argued that her injury did not occur in the performance of duty because she fell on her way to her car in the parking lot at the end of her shift. He further stated that her foot pain was nonwork related as she had complained about it for years.

In a March 23, 2016 diagnostic report, Dr. Corey A. Couto, a Board-certified diagnostic radiologist, reported that an x-ray of the left foot revealed abnormality in the heel region with soft tissue thickening present in the region of the distal Achilles. He noted calcifications extending to the attachment of the calcaneus and would correlate with heel symptoms. Dr. Couto further noted other degenerative changes including enthesophyte at the plantar fascia attachment. Findings revealed no acute fracture.

In another March 23, 2015 diagnostic report, Dr. Couto reported that an x-ray of the left ankle revealed generalized soft tissue swelling, more conspicuous medially, and no underlying fracture.

By report dated March 23, 2016, Dr. Joseph A. Sardina, a Board-certified family practitioner, related that appellant presented to urgent care with a lower left foot injury. He noted that appellant was injured at work on March 21, 2016 when she tripped over a band of plastic, causing her to limp due to swelling in her ankle and foot. On March 22, 2016 appellant returned to work, but was limping. After work, she again twisted her ankle after her foot seemed to give way. Dr. Sardina provided physical examination findings and review of diagnostic testing. An x-ray of the left ankle revealed no bony irregularity of the distal fibula or ankle joint.

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An x-ray of the foot revealed some calcification of the distal Achilles tendon. Dr. Sardina diagnosed left ankle and foot pain, noting pain in vicinity of Achilles tendon at heel. He noted no fracture, but some calcifications at distal most portion of Achilles tendon, which could be preexisting to the injuries suffered recently, although her symptoms were new. Dr. Sardina concluded that appellant sustained a strain/sprain of her left ankle and foot. He restricted her from work for seven days pending follow up.

In March 23 and 30, 2016 duty status reports (Form CA-17), Dr. Sardina restricted appellant from work.

By letter dated April 12, 2016, OWCP informed appellant that the evidence of record was insufficient to support her claim. Appellant was advised of the factual and medical evidence needed and was afforded 30 days to submit the requested evidence.

In April 13 and 27, 2016 CA-17 reports, Dr. Sardina diagnosed ankle injury and checked the box marked “work related” when asked about the cause of injury. He restricted appellant to limited duty for four hours per day and recommended physical therapy.

By decision dated May 13, 2016, OWCP accepted that appellant tripped over strapping on March 21, 2016, but denied her claim finding that the evidence of record failed to establish that her diagnosed conditions were causally related to the accepted March 21, 2016 employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA has the burden of establishing 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 filed within the applicable time limitation, that an injury was sustained while in the performance of duty as alleged, and that any disability or specific condition for which compensation is claimed are causally related to the employment injury.3 These are the essential elements of each and every compensation claim regardless of whether the claim is predicated on a traumatic injury or an occupational disease.4

In order to determine whether an employee actually sustained an injury in the performance of duty, OWCP begins with an analysis of whether fact of injury has been established. Generally, fact of injury consists of two components which must be considered in conjunction with one another. The first component to be established is that the employee actually experienced the employment incident which is alleged to have occurred.5 The second component is whether the employment incident caused a personal injury and generally can be established only by medical evidence.

3
Gary J. Watling, 52 ECAB 278 (2001); Elaine Pendleton, 40 ECAB 1143, 1154 (1989).
4
Michael E. Smith, 50 ECAB 313 (1999).
5
Elaine Pendleton, supra note 3.

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 To establish causal relationship between the condition and the employment event or incident, the employee must submit rationalized medical opinion evidence supporting such a causal relationship.6 The opinion of the physician must be based on a complete factual and medical background of the claimant, 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. This medical opinion must include an accurate history of the employee’s employment injury and must explain how the condition is related to the injury. The weight of medical evidence is determined by its reliability, its probative value, its convincing quality, the care of analysis manifested, and the medical rationale expressed in support of the physician’s opinion.7

ANALYSIS

OWCP accepted that the March 21, 2016 employment incident occurred as alleged. The issue is whether appellant established that the incident caused her left ankle and foot conditions. The Board finds that she did not submit sufficient medical evidence to support that her left ankle and foot conditions were causally related to the accepted March 21, 2016 employment incident.8

Appellant sought treatment with Dr. Sardina from March 23 through April 27, 2016. In a March 23, 2016 report, Dr. Sardina noted a history of the employment incident, provided physical examination findings, and reviewed diagnostic testing. He diagnosed strain/sprain of the left ankle and foot. The Board finds that the opinion of Dr. Sardina is not well rationalized. Dr. Sardina related that appellant could have preexisting conditions related to the left foot. The March 23, 2016 x-ray of the left foot revealed degenerative changes, as well as calcifications extending to the attachment of the calcaneus, which would correlate with heel symptoms. Dr. Sardina speculated that the calcification of the distal Achilles tendon could be preexisting to the injuries suffered, although appellant’s symptoms were new. While Dr. Sardina noted new symptoms, such generalized statements do not establish causal relationship because they merely repeat appellant’s allegations and are unsupported by adequate medical rationale explaining how this physical activity actually caused the diagnosed conditions.9 He failed to provide any support that appellant’s injury was caused or aggravated by the March 21, 2016 employment incident and, did not address why her complaints were not caused by her preexisting conditions.10 A well-rationalized opinion is particularly warranted when there is a history of preexisting condition.11 Medical evidence that does not offer any opinion regarding the cause of an

6
See 20 C.F.R. § 10.110(a); John M. Tornello, 35 ECAB 234 (1983).
7
James Mack, 43 ECAB 321 (1991).
8
See Robert Broome, 55 ECAB 339 (2004).
9
K.W., Docket No. 10-98 (issued September 10, 2010).
10
A well-rationalized opinion is particularly warranted when there is a history of preexisting condition. R.E., Docket No. 14-868 (issued September 24, 2014); T.M., Docket No. 08-975 (issued February 6, 2009); Michael S. Mina, 57 ECAB 379 (2006). 11 T.M., id.; Michael S. Mina, id.

4 employee’s condition is of limited probative value on the issue of causal relationship.12 Thus, his opinion is of limited probative value.13

Dr. Sardina’s remaining reports are also insufficient to establish appellant’s claim. His April 13, 2016 form report checked the box marked “work related” when asked about the cause of appellant’s injury. The Board has held that a report that addresses causal relationship with a checkmark, without medical rationale explaining how the work condition caused the alleged injury, is of diminished probative value and insufficient to establish causal relationship.14 Without explaining how physiologically the movements involved in the employment incident caused or contributed to the diagnosed conditions, Dr. Sardina’s opinion is of limited probative value.15

Dr. Couto’s March 23, 2016 diagnostic reports are also insufficient to establish appellant’s claim as he just interpreted diagnostic imaging studies and provided no opinion on the cause of appellant’s injury.16 In the instant case, the record lacks rationalized medical evidence establishing causal relationship between the March 21, 2016 employment incident and appellant’s strain/sprain of the left ankle and foot. Thus, appellant has failed to meet her burden of proof.

Appellant may submit new evidence, together with a written request for reconsideration, to OWCP within one year of the Board’s decision, pursuant to 5 U.S.C. § 8128(a) and 20 C.F.R.
§§ 10.605 and 10.607.

CONCLUSION

The Board finds that appellant did not meet her burden of proof to establish that she sustained a left ankle and foot injury causally related to the accepted March 21, 2016 employment incident.

12
The opinion of a physician supporting causal relationship must rest on a complete factual and medical background supported by affirmative evidence, address the specific factual and medical evidence of record, and provide medical rationale explaining the relationship between the diagnosed condition and the established incident or factor of employment. C.B., Docket No. 09-2027 (issued May 12, 2010); S.E., Docket No. 08-2214 (issued May 6, 2009). 13 P.O., Docket No. 14-1675 (issued December 3, 2015).
14
C.Y., Docket No. 14-2075 (issued March 2, 2015); 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). 15 See L.M., Docket No. 14-973 (issued August 25, 2014); R.G., Docket No. 14-113 (issued April 25, 2014);
K.M., Docket No. 13-1459 (issued December 5, 2013); A.J., Docket No. 12-548 (issued November 16, 2012). 16 J.P., Docket No. 14-87 (issued March 14, 2014).

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 ORDER

IT IS HEREBY ORDERED THAT the May 13, 2016 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: December 7, 2016
Washington, DC

Patricia H. Fitzgerald, Deputy 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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