E.O. and Department of Veterans Affairs, Regional Benefit Office, Buffalo, NY (Board decision, November 24, 2017)

ECAB final decision. The Board affirmed OWCP’s March 8, 2017 denial of the claimed 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).

Plain-English summary

E.O. fell after catching her heel on a rug while leaving work on September 8, 2014. OWCP accepted the fall as a work incident. The Board found her medical reports did not clearly identify a condition caused by that incident or explain the causal connection, so it upheld the denial.

Decision snapshot

• Authority: 5 U.S.C. § 8101.
• Outcome: March 8, 2017 injury claim denial affirmed.
• Key point: An accepted fall still required medical evidence connecting it to a diagnosed injury.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
E.O., Appellant
)
)
and ) Docket No. 17-1534
) Issued: November 24, 2017
DEPARTMENT OF VETERANS AFFAIRS,
)
REGIONAL BENEFIT OFFICE, Buffalo, NY,
)
Employer
)
__________ )

Appearances: Case Submitted on the Record
Thomas S. Harkins, Esq., for the appellant1
Office of Solicitor, for the Director

DECISION AND ORDER

Before:
PATRICIA H. FITZGERALD, Deputy Chief Judge COLLEEN DUFFY KIKO, Judge
ALEC J. KOROMILAS, Alternate Judge

JURISDICTION

On July 5, 2017 appellant, through counsel, filed a timely appeal from a March 8, 2017 merit decision of the Office of Workers’ Compensation Programs (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.

1
In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for legal or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R.
§ 501.9(e). No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An attorney or representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject to fine or imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a representative, prior to approval by the Board, may be reported to appropriate authorities for investigation. 2 5 U.S.C. § 8101 et seq.
 ISSUE

The issue is whether appellant met her burden of proof to establish an injury due to a September 8, 2014 employment incident.

FACTUAL HISTORY

On September 10, 2014 appellant, then a 63-year-old miscellaneous clerk and assistant, filed a traumatic injury claim (Form CA-1) alleging that at 4:05 p.m. on September 8, 2014 she sustained injury to her neck, shoulders, left elbow, left hand, mid back, and knees due to a fall at work. She indicated that she caught her heel on a rug in the lobby of the employing establishment premises and fell forward to the floor. Appellant stopped work on September 9, 2014 and returned to work on September 10, 2014.3

Appellant visited a Kaleida health clinic on an emergency basis on September 17, 2014 and was treated by Dr. James David, a Board-certified internist. In his October 9, 2014 report of the visit,4 Dr. David indicated that she visited after she tripped and fell at work, landing on her knees. Appellant reported being able to get up and walk away with assistance after the fall. Dr. David noted, “Also complains of shoulder pains. The onset was [two] hours ago.” He reported findings on physical examination, including normal motion and strength of the lower extremities and bilateral knee tenderness. Dr. David provided a diagnosis of contusion.

In a September 30, 2014 report, Dr. Michael Geraci, Jr., an attending Board-certified physical medicine and rehabilitation physician, indicated that appellant presented for an initial consultation on September 30, 2014 primarily regarding a new problem that occurred on September 8, 2014. Appellant reported that she was walking through the lobby at work when her heel caught on the carpet and she fell forward onto her hands and knees. Dr. Geraci reported the findings of his September 30, 2014 physical examination noting that she had 50 percent loss in cervical extension and 25 percent loss in flexion, but displayed full rotation and side bending.5 He reported normal results of strength, deep tendon reflexes, and sensory examination, and noted negative findings upon upper limb tension and straight leg testing bilaterally.

Appellant’s knee examination reproduced patello-femoral pain, but there was no joint instability, ligaments were intact, and the cartilage compression test was negative. Dr. Geraci diagnosed bilateral knee pain with patella-femoral pain syndrome, C5-6 focal disc herniation with disc osteophyte complex, chronic neck pain, right upper extremity radiculitis, cervical

3
On the reverse side of the claim form, appellant’s immediate supervisor indicated that appellant’s regular work hours were 7:30 a.m. to 4:00 p.m., Monday through Friday. He indicated that she fell while she was exiting the building after the end of her tour of duty. The record contains a September 10, 2014 report of contact in which appellant’s immediate supervisor noted that appellant advised him on September 9, 2014 that she tripped on a rug and fell at work on September 8, 2014. 4 Dr. David indicated that he was writing the report from memory as he “apparently did not complete it at the time of patient visit.”
5
Appellant’s range of lumbar motion was limited by 50 percent in extension and 25 percent in side bending and rotation, but she exhibited full flexion. Range of motion in the hips and shoulders was within normal limits.

2 spondylosis and stenosis, and right shoulder rotator cuff tear. He noted that the incident that appellant described was “the competent medical cause of the injury.” Dr. Geraci indicated that appellant’s complaints were consistent with the injury and her history of the injury was consistent with the objective findings of his examination.

In an attending physician’s report (Form CA-20) dated September 30, 2014, Dr. Geraci listed the date of injury as September 8, 2014. He diagnosed bilateral knee pain, chronic neck pain, right upper extremity radiculitis, cervical spondylosis and stenosis, and rotator cuff tear of the right shoulder and checked a box marked “No” in response to a question regarding whether there was any history or evidence of concurrent or preexisting injury, disease, or physical impairment. Dr. Geraci also checked a box marked “No” in response to a question regarding whether he believed that the condition found was caused or aggravated by an employment activity. He noted that appellant was able to resume regular duty on October 1, 2014.

In December 1, 2014 report, Dr. Geraci indicated that appellant presented complaining of neck pain radiating into her left upper extremity and bilateral knee pain. Upon physical examination, appellant’s range of cervical motion was limited by 25 percent, but she had normal flexion, rotation, and side bending. Dr. Geraci reiterated that the strength, deep tendon reflexes, and sensory examinations were normal, except for right shoulder supraspinatus/infraspinatus isolation tests which were positive. He diagnosed bilateral patellar femoral pain syndrome, C5-6 focal disc herniation with disc osteophyte complex, chronic neck pain, right upper extremity radiculitis, cervical spondylosis and stenosis, and right shoulder rotator cuff tear involving both the supraspinatus and infraspinatus tendons. Dr. Geraci again noted that the incident that appellant described was “the competent medical cause of the injury.” He indicated that her complaints were consistent with the injury and her history of the injury was consistent with the objective findings of his examination.

In a December 1, 2014 Form CA-20, Dr. Geraci listed the date of injury as September 8, 2014. He diagnosed bilateral knee pain, chronic neck pain, right upper extremity radiculitis, cervical spondylosis and stenosis, and rotator cuff tear of the right shoulder and checked a box marked “No” in response to a question regarding whether he believed that the condition found was caused or aggravated by an employment activity.

In a December 11, 2015 Form CA-20, Dr. Peter Gambacorta, an attending Board- certified orthopedic surgeon and osteopath, listed the date of injury as September 8, 2014 and the mechanism of injury in section 4 of the form as “fell in kitchen, caught her right arm on table.” He diagnosed right shoulder and cervical spine pain. In section 8, Dr. Gambacorta checked a box marked “Yes” in response to a question regarding whether he believed that the condition found was caused or aggravated by an employment activity listed in section 4. It is noted that section 8 also contains the notation “fell at work,” which appears to be in a different handwriting than that of the rest of the form. Dr. Gambacorta indicated that he first examined appellant on August 15, 2013 and advised that she was able to resume her regular work on that date.

3
 In a February 1, 2017 letter, OWCP requested that appellant submit additional evidence in support of her claim, including a physician’s opinion supported by a medical explanation as to how the September 8, 2014 work incident caused or aggravated a medical condition.6

In March 1 and 2, 2017 letters, counsel noted that appellant had reported that she was on the employing establishment premises when she fell while leaving work on September 8, 2014. He asserted that the medical evidence of record showed that appellant sustained injury due to the September 8, 2014 employment incident.

In a March 8, 2017 decision, OWCP denied appellant’s claim for a September 8, 2014 traumatic injury. It accepted that she had established the occurrence of an employment incident when she tripped on a rug and fell on September 8, 2014, but found that she had not submitted sufficient medical evidence to establish causal relationship between a diagnosed medical condition and the accepted employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA7 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, that an injury was sustained in the performance of duty as alleged and that any disability and/or specific condition for which compensation is claimed are causally related to the employment injury.8 These are the essential elements of each compensation claim regardless of whether the claim is predicated upon a traumatic injury or an occupational disease.9

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 she actually experienced the employment incident at

6
OWCP also asked appellant whether she was on the employing establishment premises and performing regularly assigned duties when she fell on September 8, 2014. In a February 1, 2017 letter, it asked the employing establishment to respond to a question regarding whether, at the time of her September 8, 2014 fall, she was on premises which were owned, operated, or controlled by the employing establishment. OWCP advised that 20 C.F.R.
§ 10.117(b) of its regulations provides that, in the absence of a full reply from the employing establishment, it may accept an employee’s allegations as factual. The employing establishment did not respond to the February 1, 2017 letter. 7 Supra note 2.
8
C.S., Docket No. 08-1585 (issued March 3, 2009); Elaine Pendleton, 40 ECAB 1143 (1989).
9
S.P., 59 ECAB 184 (2007); Victor J. Woodhams, 41 ECAB 345 (1989). A traumatic injury refers to injury caused by a specific event or incident or series of incidents occurring within a single workday or work shift whereas an occupational disease refers to an injury produced by employment factors which occur or are present over a period longer than a single workday or work shift. 20 C.F.R. § 10.5(q), (ee); Brady L. Fowler, 44 ECAB 343, 351 (1992).

4 the time, place, and in the manner alleged.10 Second, the employee must submit evidence, in the form of medical evidence, to establish that the employment incident caused a personal injury.11

Causal relationship is a medical issue and the medical evidence generally required to establish causal relationship is rationalized medical opinion evidence. 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.12

ANALYSIS

Appellant claimed that she sustained injury to her neck, shoulders, left elbow, left hand, mid back, and knees due to a fall at work on September 8, 2014. She indicated that she caught her heel on a rug in the lobby of the employing establishment premises while leaving work and fell forward to the floor.

OWCP accepted that appellant’s September 8, 2014 fall constituted an employment incident occurring in the performance of duty. The Board finds, however, that OWCP properly denied her claim because she had not submitted sufficient medical evidence to establish a diagnosed medical condition due to the accepted September 8, 2014 employment incident.

In a report of appellant’s September 17, 2014 visit to a clinic on an emergency basis, Dr. David provided her description of a fall at work, but did not mention the date of the fall. He did, however, note that she reported her onset of symptoms was two hours prior. Dr. David detailed examination findings and provided a diagnosis of contusion. This report is of limited probative value with respect to establishing appellant’s claim of a September 8, 2014 employment injury because he did not clearly specify the nature of the contusion or provide any opinion that the diagnosed condition was due to the September 8, 2014 fall. The Board has held that medical evidence which does not offer a clear opinion regarding the cause of an employee’s condition is of limited probative value on the issue of causal relationship.13

In his September 30, 2014 report, Dr. Geraci provided a description of the September 8, 2014 fall and detailed physical examination findings. He diagnosed bilateral knee pain with patella-femoral pain syndrome, C5-6 focal disc herniation with disc osteophyte complex, chronic neck pain, right upper extremity radiculitis, cervical spondylosis and stenosis, and right shoulder rotator cuff tear. Dr. Geraci noted that the incident that appellant described was “the competent medical cause of the injury.” He indicated that her complaints were consistent with the injury and her history of the injury was consistent with the objective findings of his examination. This report is of limited probative value with respect to establishing appellant’s claim of a

10
Julie B. Hawkins, 38 ECAB 393 (1987).
11
John J. Carlone, 41 ECAB 354 (1989).
12
See I.J., 59 ECAB 408 (2008); Donna Faye Cardwell, 41 ECAB 730 (1990).
13
See Charles H. Tomaszewski, 39 ECAB 461 (1988).

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September 8, 2014 employment injury, however, because Dr. Geraci did not provide medical rationale in support of his conclusion on causal relationship. The Board has held that a medical report is of limited probative value on the issue of causal relationship if it contains a conclusion regarding causal relationship which is unsupported by medical rationale.14

Dr. Geraci also indicated that his opinion on causal relationship was supported by the objective findings of his examination, but he did not provide any discussion of the specific findings he felt supported his finding. He diagnosed a wide variety of medical conditions, but he did not discuss the September 8, 2014 employment injury in any detail or explain how it would have been competent to cause or aggravate these conditions. As well, Dr. Geraci failed to provide a detailed discussion of appellant’s prior medical history, and therefore his opinion is of limited probative value for the further reason that it was not based on a complete medical history.15

The Board further notes that additional questions are raised about Dr. Geraci’s opinion on causal relationship by a form report he completed on September 30, 2014, the same date as the above-described narrative report was completed. In this form report, Dr. Geraci listed the date of injury as September 8, 2014 and diagnosed bilateral knee pain, chronic neck pain, right upper extremity radiculitis, cervical spondylosis and stenosis, and rotator cuff tear of the right shoulder.16 However, he checked a box marked “No” in response to a question regarding whether he believed that the condition found was caused or aggravated by an employment activity. Dr. Geraci did not explain this ostensible discrepancy with his September 30, 2014 narrative report. The Board has held that an opinion on causal relationship which is equivocal in nature is of limited probative value regarding the issue of causal relationship.17

Dr. Geraci’s December 1, 2014 narrative report contained a similar list of diagnoses and the same general, nonspecific opinion on causal relationship that was provided in his September 30, 2014 report. Therefore, his December 1, 2014 report is of limited probative value on the relevant issue of this case for the same reason as his September 30, 2014 report, i.e., he failed to provide a rationalized medical opinion relating a diagnosed condition to the September 8, 2014 employment incident.18 In a December 1, 2014 form report, Dr. Geraci listed the same diagnoses as listed in his September 30, 2014 form report and checked a box marked “No” in response to a question regarding whether he believed that the condition found was caused or aggravated by an employment activity. Therefore, this form report further highlights the equivocal nature of his opinion on causal relationship.19

14
C.M., Docket No. 14-0088 (issued April 18, 2014).
15
See supra note 12.
16
Dr. Geraci also provided the ICD-9 codes for pain in joint, lower leg (719.46), displacement of cervical intervertebral disc without myelopathy (722.0), cervalgia (723.1), and disorder of bursae and tendons in shoulder region, unspecified (726.10). 17 See Leonard J. O’Keefe, 14 ECAB 42, 48 (1962); James P. Reed, 9 ECAB 193, 195 (1956).
18
See Y.D., Docket No. 16-1896 (issued February 10, 2017).
19
See supra note 17.

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 In the December 11, 2015 Form CA-20, Dr. Gambacorta, listed the date of injury as September 8, 2014 and the mechanism of injury in Box 4 as “fell in kitchen, caught her right arm on table.” He diagnosed right shoulder and cervical spine pain.20 In section 8, Dr. Gambacorta checked a box marked “Yes” in response to a question regarding whether he believed that the condition found was caused or aggravated by an employment activity listed in section 4. The Board notes that this report would not establish appellant’s claim for a September 8, 2014 employment injury because he did not provide a clear, unequivocal opinion that she sustained a diagnosed condition due the September 8, 2014 employment incident. As noted above, the Board has held that an opinion on causal relationship which is equivocal in nature is of limited probative value regarding the issue of causal relationship.21 By checking the box marked “Yes” in section 8, Dr. Gambacorta related appellant’s condition to a nonwork incident that occurred at her home. Section 8 also contains the notation “fell at work,” but this appears to be in a different handwriting than that of the rest of the form and there is no further description of the date or nature of the indicated fall. Dr. Gambacorta’s report is of limited probative value because it does not contain a rationalized medical opinion relating a diagnosed condition to a specific employment incident. The Board has held that a medical opinion is of limited probative value on the matter of causal relationship if it does not contain a rationalized medical opinion relating a diagnosed condition to a specific employment incident.22

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 has not met her burden of proof to establish an injury due to the September 8, 2014 employment incident.

20
Dr. Gambacorta also provided the ICD-10 code for pain in right shoulder (M25.511) and two other codes that were not identifiable.
21
See supra note 17.
22
See D.R., Docket No. 16-0528 (issued August 24, 2016). On appeal counsel argues that the record contains factual and medical evidence establishing appellant’s claim for a September 8, 2014 employment injury, but the Board has explained the deficiencies in the medical evidence.

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 ORDER

IT IS HEREBY ORDERED THAT the March 8, 2017 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: November 24, 2017
Washington, DC

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

Colleen Duffy Kiko, Judge
Employees’ Compensation Appeals Board

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

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