L.S. and U.S. Postal Service, Post Office, Great Barrington, MA (Board decision, February 19, 2020)

ECAB final decision. The Board affirmed OWCP’s August 31, 2017 denial of left ankle and bilateral knee conditions attributed to postal work. 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 postal carrier attributed ankle and knee conditions to standing, walking, carrying mail, and other route duties. Two physicians gave no specific diagnosis. Two others did not adequately explain how the work duties caused or aggravated the diagnosed conditions; one noted her existing lower limb problems, which made a reasoned causal explanation especially important. The Board affirmed the claim denial.

Decision snapshot

• Authority: FECA medical causation requirement.
• Outcome: OWCP’s August 31, 2017 ankle and knee claim denial affirmed.
• Key point: The supportive opinions did not adequately explain causation for the diagnosed conditions.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
L.S., Appellant
)
)
and ) Docket No. 18-0518
) Issued: February 19, 2020
U.S. POSTAL SERVICE, POST OFFICE,
)
Great Barrington, MA, Employer
)
__________ )

Appearances: Case Submitted on the Record
Appellant, pro se
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 16, 2018 appellant filed a timely appeal from an August 31, 2017 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 her burden of proof to establish left ankle and bilateral knee conditions causally related to the accepted factors of her federal employment.

FACTUAL HISTORY

On June 1, 2016 appellant, a 51-year-old city letter carrier, filed an occupational disease claim (Form CA-2) alleging that she sustained an injury due to factors of her federal employment. She indicated that she first became aware of her condition and first realized it was caused or

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5 U.S.C. § 8101 et seq. aggravated by factors of her federal employment on September 2, 2015. Appellant stopped work and has not returned.2

In a narrative statement submitted with her claim, appellant indicated that she transferred to her duty station in January 1997 and had walked with a 35-pound bag six days a week, up to 56 hours per week while delivering her mail route. She identified the factors of employment that she believed caused her conditions including standing, walking, carrying heavy packages, climbing stairs, climbing in and out of vehicles, and walking on uneven ground. Appellant indicated that as time went on she had experienced left ankle pain and right knee pain. She noted that she could not walk longer than 15 minutes with pain shooting up her leg and around her knee. Appellant noted that she was waiting for a total knee replacement.

In a March 18, 2016 report, Dr. Albert A. Bravo, a podiatrist, noted that appellant had been seen and treated for pain in her left hindfoot and ankle area. He reported that she had long-standing problems with her feet and in March 2007 noticed a change in the configuration of her arch. In November 2007, the pain had recurred and appellant wore various types of arch supports and heel lifts, which were unable to alleviate her symptoms. Dr. Bravo noted that in September 2014 appellant had undergone injection therapy and options concerning more aggressive bracing were discussed. Appellant underwent triple arthrodesis surgery in an effort to stabilize the foot and alleviate her symptoms. Dr. Bravo opined that her symptomatology was significantly aggravated by her work activities and noted that her duties required significant amounts of standing, walking, carrying heavy packages, climbing stairs, and climbing in and out of vehicles which caused excessive mechanical strain on the foot. He further opined that this contributed to the chronic pain requiring surgery at the left hindfoot area and appellant’s foot condition also directly contributed to her knee problems.

On May 26, 2016 Dr. Pier B. Boutin, a Board-certified orthopedic surgeon, noted that appellant first consulted his office on August 25, 2014 after injuring her left knee and ankle. He indicated that she had reported an employment injury on April 8, 2014 and her symptoms apparently began as a result of excessive walking and stairs and that the pain became so severe that she had difficulty performing her duties. Dr. Boutin diagnosed an aggravation of knee arthritis and ankle arthritis based on x-rays from August 26, 2014 and June 5, 2015 and based upon appellant’s physical examination. He opined that her symptoms were no longer controlled with conservative treatment and she was a candidate for bilateral total knee replacements. Dr. Boutin further opined that appellant’s federal duties for the past 20 years had markedly aggravated her condition and were also a major contribution to her present condition. He recommended a future knee replacements and an ankle fusion.

In a development letter dated June 14, 2016, OWCP advised appellant of the deficiencies in her claim and informed her of the additional evidence necessary to establish her claim. It provided a questionnaire for her completion and afforded her 30 days to respond.

2
In a letter dated June 14, 2016, OWCP informed appellant that it had inadvertently created a duplicate claim file and thus deleted OWCP File No. xxxxxx111. It further informed her that the case would proceed under OWCP File No. xxxxxx133, the current claim.

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 On June 17, 2018 the employing establishment controverted the claim asserting that appellant failed to establish causal relationship. It provided a statement from her postmaster who noted embellishment on the part of appellant in describing the employment duties of her position.

In response to the development letter, appellant submitted an x-ray of her right knee dated June 5, 2015 which showed osteoarthritis and patellofemoral joint, as well as evidence of a joint effusion with a fatty structure in the suprapatellar region. An August 26, 2014 x-ray of her left ankle demonstrated mild lateral ankle soft tissue swelling, mild anterior ankle soft tissue swelling, and mild osteoarthritis changes at the tibiotalar joint and distal fibula. An August 26, 2014 x-ray of appellant’s knees, read by Dr. Sanjay Kedia, a diagnostic radiologist, revealed chronic appearing depression of the articular surface of the right lateral tibial plateau “may be due to old trauma,” small periarticular osteophytes of the right knee, and unremarkable left knee.

By decision dated September 6, 2016, OWCP denied the claim finding that the medical evidence of record failed to establish a causal relationship between appellant’s diagnosed conditions and the accepted factors of her federal employment.

Appellant subsequently submitted work excuse notes dated August 1, September 29, and October 27, 2016 from Dr. Jeffrey P. Cella, a Board-certified orthopedic surgeon, who diagnosed right knee degenerative joint disease (DJD) status post right knee replacement and moderate arthritis of the left knee. Dr. Cella opined that she was capable of working six hours per day with minimal walking and standing and lifting no more than 20 pounds.

On June 7, 2017 appellant requested reconsideration.

In an October 12, 2016 report, Dr. Cella opined that appellant’s diagnosed condition of knee DJD status post right total knee replacement was significantly aggravated by her work activities as they included significant amounts of standing, walking, carrying heavy packages, climbing stairs, climbing in and out of vehicles, and walking on uneven ground. He further opined that her duties had caused an excessive mechanical strain on the right knee.

On January 31, 2017 Dr. David Dixon, a Board-certified orthopedic surgeon, reviewed appellant’s left foot and ankle x-rays and found that they revealed healed triple arthrodesis for the most part, good alignment noted, and almost full healing across all three joints. He opined that she was not capable of fully standing all day at work and could only return to a sedentary position. Dr. Dixon further opined that appellant was totally disabled for work due to her left ankle condition and right end-stage knee arthritis.

In a May 23, 2017 report, Dr. Cella indicated that he had treated appellant for her bilateral knee issues and had only examined her left ankle for stability to support her right knee replacement. He noted that she had recovered from her knee replacement and was doing well. Dr. Cella indicated that he had returned appellant to work with no formal restrictions.

By decision dated August 31, 2017, OWCP denied modification of its prior decision.

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 LEGAL PRECEDENT

An employee seeking benefits under FECA3 has the burden of proof to establish the essential elements of his or her claim, including 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 of FECA,4 that an injury was sustained in the performance of duty as alleged, and that any disability or medical condition for which compensation is claimed is causally related to the employment injury.5 These are the essential elements of each and every compensation claim, regardless of whether the claim is predicated upon a traumatic injury or an occupational disease.6

To establish that an injury was sustained in the performance of duty in an occupational disease claim, a claimant must submit: (1) a factual statement identifying employment factors alleged to have caused or contributed to the presence or occurrence of the disease or condition; (2) medical evidence establishing the presence or existence of the disease or condition for which compensation is claimed; and (3) medical evidence establishing that the diagnosed condition is causally related to the employment factors identified by the claimant.7

Causal relationship is a medical issue, and the medical evidence required to establish causal relationship is rationalized medical opinion evidence.8 The opinion of the physician must be based on a complete factual and medical background of the employee, 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 specific employment factors identified by the employee.9

In any case where a preexisting condition involving the same part of the body is present and the issue of causal relationship therefore involves aggravation, acceleration or precipitation, the physician must provide a rationalized medical opinion that differentiates between the effects of the work-related injury or disease and the preexisting condition.10

3
Supra note 1.
4
S.B., Docket No. 17-1779 (issued February 7, 2018); J.P., 59 ECAB 178 (2007); Joe D. Cameron, 41 ECAB 153 (1989).
5
J.M., Docket No. 17-0284 (issued February 7, 2018); R.C., 59 ECAB 427 (2008); James E. Chadden, Sr., 40 ECAB 312 (1988). 6 K.M., Docket No. 15-1660 (issued September 16, 2016); L.M., Docket No. 13-1402 (issued February 7, 2014);
Delores C. Ellyett, 41 ECAB 992 (1990).
7
S.C., Docket No. 18-1242 (issued March 13, 2019); R.H., 59 ECAB 382 (2008).
8
A.M., Docket No. 18-1748 (issued April 24, 2019); T.H., 59 ECAB 388, 393 (2008); Robert G. Morris, 48 ECAB 238 (1996).
9
M.V., Docket No. 18-0884 (issued December 28, 2018); I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345, 352 (1989). 10 Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3e (January 2013);
N.C., Docket No. 19-1191 (issued December 19, 2019); R.D., Docket No. 18-1551 (issued March 1, 2019) .

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 ANALYSIS

The Board finds that appellant has not met her burden of proof to establish left ankle and bilateral knee conditions causally related to the accepted factors of her federal employment.

In his March 18, 2016 report, Dr. Bravo noted that treatment was provided for appellant’s left hindfoot and ankle. He noted her long-standing problems with her feet. Dr. Bravo opined that appellant’s symptomatology had been significantly aggravated by her work activities and noted that her duties required significant amounts of standing, walking, carrying heavy packages, climbing stairs, and climbing in and out of vehicles, which caused excessive mechanical strain on the foot. He further opined that her duties contributed to the chronic pain requiring surgery at the left hindfoot area and that her foot condition also directly contributed to her knee problems. Although he provided an opinion on causal relationship, Dr. Bravo did not specifically diagnose either a left ankle or knee conditions and generally noted appellant’s pain. It is not possible to establish the cause of a medical condition if the physician has not provided a diagnosis, but only notes pain.11 The Board has consistently held that pain is a symptom and not a compensable medical diagnosis.12 For these reasons, this report from Dr. Bravo is insufficient to establish a medical diagnosis in connection with the accepted employment factors.

Dr. Dixon, in his January 31, 2017 report, opined that appellant was totally disabled for work due to her left ankle condition and right end-stage knee arthritis. He also failed to provide a specific diagnosis, merely noting her continued symptoms.13 Thus, Dr. Dixon’s reports are also insufficient to establish a medical condition causally related to the accepted employment factors.

On May 26, 2016 Dr. Boutin noted that appellant had reported an employment injury on April 8, 2014 and her symptoms apparently began as a result of excessive walking and stairs and the pain became so severe that she had difficulty performing her duties. He diagnosed an aggravation of knee arthritis and ankle arthritis based on x-ray results and upon her physical examination. Dr. Boutin opined that appellant’s federal duties for the past 20 years had markedly aggravated her condition and were also a major contribution to her present condition. However, while he diagnosed medical conditions and provided an opinion that they were work related, he failed to provide the necessary rationale in support of his opinion. The Board has held that a report is of limited probative value regarding causal relationship if it does not contain medical rationale explaining how a given medical condition was related to employment factors.14 Due to this deficiency, Dr. Boutin’s report is insufficient to establish the claim.

In his reports, Dr. Cella diagnosed right knee DJD status post right knee replacement and moderate arthritis of the left knee. He opined that appellant’s right knee condition was significantly aggravated by her work activities as they included significant amounts of standing,

11
See A.C., Docket No. 16-1587 (issued December 27, 2016).
12
B.P., Docket No. 12-1345 (issued November 13, 2012); C.F., Docket No. 08-1102 (issued October 2008).
13
Supra note 11.
14
D.L., Docket No. 19-0900 (issued October 28, 2019); Y.D., Docket No. 16-1896 (issued February 10, 2017);
C.M., Docket No. 14-0088 (issued April 18, 2014).

5 walking, carrying heavy packages, climbing stairs, climbing in and out of vehicles, and walking on uneven ground. Dr. Cella further opined that her employment duties had caused an excessive mechanical strain on the right knee. On May 23, 2017 he indicated that he had treated appellant for her knees and had only examined her left ankle for stability to support her right knee replacement. The Board finds that Dr. Cella failed to provide sufficient medical rationale explaining how standing, walking, carrying heavy packages, climbing stairs, climbing in and out of vehicles, and walking on uneven ground at work either caused or contributed to her diagnosed conditions. While Dr. Cella diagnosed medical conditions, his opinion lacks the necessary medical rationale to explain how and why the accepted factors were sufficient to result in the diagnosed medical conditions.15 Such rationale is especially important in this case as he noted appellant’s preexisting lower extremity conditions.16 Therefore, the reports from Dr. Cella are insufficient to meet her burden of proof to establish her claim.

The x-rays of the left ankle and knees, read by Dr. Kedia, confirmed the diagnoses for appellant’s left ankle and knee conditions. The Board has held, however, that diagnostic studies such as x-rays lack probative value on the issue of causal relationship as they do not address whether the employment incident caused any of the diagnosed conditions.17

The Board thus finds that appellant has not submitted rationalized medical evidence of sufficient probative value to support her claim for left ankle and bilateral knee conditions causally related to the accepted factors of her federal employment and therefore she has not met her burden of proof to establish her claim.

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 left ankle and bilateral knee conditions causally related to the accepted factors of her federal employment.

15
J.D., Docket No. 14-2061 (issued February 27, 2015).
16
Supra note 10.
17
J.P., Docket No. 19-0216 (issued December 13, 2019); A.B., Docket No. 17-0301 (issued May 19, 2017).

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 ORDER

IT IS HEREBY ORDERED THAT the August 31, 2017 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: February 19, 2020
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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