R.S. and U.S. Postal Service, Hudson Post Office, Hudson, WI (Board decision, February 23, 2023)

ECAB final decision. The Board affirmed OWCP's denial of the left wrist injury claim. A party may petition the Board for reconsideration within 30 days of issuance unless this order specifies another period, under 20 C.F.R. § 501.7(a).

Plain-English summary

A rural carrier reported that his left wrist hurt after lifting a package while casing mail and later underwent wrist surgery. OWCP accepted the workplace incident but denied the injury claim. Two surgeons attributed a cartilage flap found during surgery to the incident, citing the onset of symptoms and improvement after surgery. The Board found that their reports did not explain medically how the incident caused the wrist condition. It affirmed OWCP's denial because the record lacked a sufficiently reasoned causation opinion.

Decision snapshot

• Authority: FECA requirement for reasoned medical evidence linking a diagnosed condition to a workplace incident.
• Outcome: OWCP's December 4, 2020 and March 26, 2021 decisions affirmed.
• Key point: Timing of symptoms and improvement after treatment did not replace a medical explanation of causation.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
R.S., Appellant
)
)
and ) Docket No. 21-0803
) Issued: February 23, 2023
U.S. POSTAL SERVICE, HUDSON POST
)
OFFICE, Hudson, WI, Employer
)
__________ )

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

DECISION AND ORDER

Before:
ALEC J. KOROMILAS, Chief Judge
JANICE B. ASKIN, Judge
VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On April 30, 2021 appellant filed a timely appeal from December 4, 2020 and March 26, 2021 merit decisions 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 his burden of proof to establish a left wrist condition causally related to the accepted March 16, 2019 employment incident.

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5 U.S.C. § 8101 et seq.
 FACTUAL HISTORY

On March 20, 2019 appellant, then a 41-year-old rural carrier, filed a traumatic injury claim (Form CA-1) alleging that on March 16, 2019 he injured his left wrist when casing mail while in the performance of duty. He stopped work on that date.

In a March 20, 2019 visit note, Michelle Schorn, a nurse practitioner, noted that appellant related that his job duties included repetitive use of his left wrist for pulling mail out of trays and lifting large packages. Appellant related that his symptoms usually occurred due to the repetitive motion of delivering mail, but had been constant since March 16, 2019. Ms. Schorn performed a physical examination, which revealed left anterior forearm and wrist pain that radiated to the first through third digits with numbness and positive Tinel’s sign and Phalen’s testing on the left. In a separate note of even date, she diagnosed left wrist carpal tunnel syndrome and recommended that appellant apply a wrist splint, ice, and heat. Ms. Schorn released him to return to work effective March 21, 2019 with restrictions.

By letter dated April 2, 2019, the employing establishment controverted appellant’s claim based upon a lack of medical documentation of causal relationship between the claimed employment incident and his left wrist condition.

In a note dated April 4, 2019, Dr. Jarrod Yamanaka, a family practitioner, opined that appellant’s left hand and wrist symptoms were the result of repetitive use of the left arm at work. She ordered an electromyogram and nerve conduction velocity (EMG/NCV) study of the left upper extremity and recommended he remain off work.

In an April 23, 2019 development letter, OWCP informed appellant of the deficiencies of his claim. It advised him of the type of factual and medical evidence needed and afforded him 30 days to respond.

OWCP thereafter received an April 3, 2019 visit note by Anne Hastings, a physician assistant, who noted that appellant related a history of gradually worsening left wrist pain, numbness, and tingling over the past six months which he attributed to repetitive grasping and sorting at work. On physical examination, Ms. Hastings observed tenderness of the distal radius and proximal thenar eminence, painful left flexion, and positive Tinel’s sign and Phalen’s testing on the left. She diagnosed carpal tunnel syndrome of the left wrist and recommended that he undergo an EMG.

By decision dated May 29, 2019, OWCP denied appellant’s traumatic injury claim, finding that the evidence of record was insufficient to establish that his diagnosed conditions were causally related to the accepted March 16, 2019 employment incident.

OWCP thereafter received a May 13, 2019 report wherein Dr. Scott Ahrenholz, a pediatrician and sports medicine specialist, noted that appellant complained of left wrist pain, numbness, and tingling, which he attributed to an incident on March 16, 2019 when his left wrist collapsed while he was grabbing an item behind his seat. Dr. Ahrenholz performed a physical examination, which revealed painful wrist extension and flexion, numbness with digital motion,

2 positive Tinel’s sign over the carpal tunnel, limited Phalen’s testing due to pain, and positive reverse Phalen’s testing. He diagnosed carpal tunnel syndrome.

In a separate note also dated May 13, 2019, Dr. Ahrenholz recommended that appellant remain off work until he could undergo EMG/NCV testing of the left wrist.

On July 23, 2019 appellant requested reconsideration.

OWCP thereafter received a report of an EMG/NCV study completed on June 19, 2019, which was normal.

On July 5, 2019 Dr. Yamanaka administered an injection to appellant’s left wrist and recommended he remain off work until July 22, 2019 to recover from the procedure.

In a July 17, 2019 report, Dr. Ahrenholz noted that appellant had sustained a traumatic left wrist injury on March 16, 2019, and that the injection had provided good relief of his symptoms.

In a report dated July 18, 2019, Dr. Troy Dean Wolter, a Board-certified orthopedic surgeon, related that appellant’s left wrist collapsed on March 16, 2019 when he grabbed a package from behind his seat. He noted that the EMG/NCV study was normal, and the injection by Dr. Yamanaka on July 5, 2019 had provided some relief of his symptoms, although certain movements and activities continue to cause pain. Dr. Wolter performed a physical examination which revealed decreased grip strength on the left compared to the right and positive Tinel’s sign, Phalen’s test, and flexion/compression test. He also documented moderate tenderness in the volar wrist over the transverse carpal ligament, flexor carpi radialis insertion, flexor carpi ulnaris, distal radioulnar joint, ulnar fovea, snuff box and dorsal wrist over the scapholunate interval. Dr. Wolter opined that appellant’s presentation was only partly consistent with carpal tunnel syndrome, and that he may have a multi-factorial wrist/ligamentous injury. On that basis, he recommended a magnetic resonance (MR) arthrogram of the left wrist for further evaluation.

A report of an MR arthrogram dated July 26, 2019 noted a tear of the scapholunate ligament.

By note dated July 31, 2019, Dr. Wolter diagnosed left wrist pain and a scapholunate ligament tear. He recommended he remain off work until he could be seen by Dr. Ariel Williams, a Board-certified orthopedic hand surgeon, on August 16, 2019.

In a report dated August 16, 2019, Dr. Williams noted appellant’s history of left wrist pain following an incident in March 2019 when he grabbed a package about the size of a shoebox with his left hand, which he did not realize weighed about 40 pounds. She further noted that his wrist collapsed when he moved the package, which caused immediate pain, especially with gripping. Dr. Williams reviewed appellant’s EMG/NCV and MR arthrogram studies and noted that he had received an injection by Dr. Yamanaka. On physical examination, she documented tenderness over the scapholunate interval and scapholunate shuck, a positive Tinel’s sign, and a positive carpal tunnel compression test. Dr. Williams diagnosed a tear of the scapholunate ligament and discussed proceeding with left wrist diagnostic arthroscopy, possible scapholunate ligament debridement versus repair, and carpal tunnel release.

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 By decision dated September 18, 2019, OWCP denied modification of its May 29, 2019 decision.

On August 27, 2019 appellant underwent left wrist fluoroscopic examination under anesthesia, diagnostic arthroscopy, debridement of a lunotriquetral ligament tear and triquetral chondromalacia, removal of a loose body, and carpal tunnel release. Dr. Williams noted postoperative diagnoses of left wrist pain, carpal tunnel syndrome, Geissler grade 3 lunotriquetral ligament tear, triquetral chondromalacia, and loose body in joint.

In an initial therapy evaluation report dated September 11, 2019, Ashley Enke, a physical therapist, recommended various postsurgical therapeutic treatment modalities.

On February 4, 2020 appellant requested reconsideration.

OWCP thereafter received an October 4, 2019 surgical follow-up report by Dr. Williams, who noted that appellant believed that the March 16, 2019 employment incident was responsible for his left wrist condition, and that he did not have symptoms whatsoever prior to that incident. Dr. Williams indicated that surgery had greatly improved his symptoms, and his physical examination was normal, with the exception of diminished wrist extension on the left compared to the right. She released appellant to return to work with restrictions of lifting no more than 10 pounds for the preceding six weeks, after which he could return to work without restrictions.

By decision dated April 23, 2020, OWCP denied modification of its September 18, 2019 decision.

In a June 29, 2020 narrative, Dr. Williams reiterated appellant’s history of an onset of left wrist pain after his wrist collapsed while he was lifting a heavy package at work on March 16, 2019. She outlined her surgical treatment and diagnosed a lunotriquetral ligament tear, low-grade triquetral chondromalacia, and large flap of cartilaginous appearing material floating in the joint. Dr. Williams opined that the flap was the primary cause of his discomfort and that the flap was most likely caused by the March 16, 2019 employment incident.

On September 9, 2020 appellant requested reconsideration.

By decision dated December 4, 2020, OWCP denied modification of its April 23, 2020 decision.

On February 16, 2021 appellant requested reconsideration. In support of his request, he submitted a January 29, 2021 narrative by Dr. Geneva V. Tranchida, an orthopedic surgeon, who noted his history of lifting a package on March 16, 2019 and that she had taken over his care from Dr. Williams. Dr. Tranchida reiterated appellant’s surgical treatment and diagnoses as previously outlined by Dr. Williams. She opined within a degree of medical probability that the mechanical pain from the large cartilage flap was the primary cause of his wrist discomfort, because he had no history of wrist pain prior to March 16, 2019 and had experienced immediate improvement in wrist pain following surgery.

By decision dated March 26, 2021, OWCP denied modification of its December 4, 2020 decision.

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 LEGAL PRECEDENT

An employee seeking benefits under FECA2 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,3 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.4 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.5

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. The first component is that the employee must submit sufficient evidence to establish that he or she actually experienced the employment incident at the time and place, and in the manner alleged. The second component is whether the employment incident caused a personal injury and can be established only by medical evidence.6

The medical evidence required to establish causal relationship between a claimed specific condition and an employment incident is rationalized medical opinion evidence.7 A physician’s opinion on whether there is causal relationship between the diagnosed condition and the implicated employment incident must be based on a complete factual and medical background.8 Additionally, the physician’s opinion must be expressed in terms of a reasonable degree of medical certainty, and must be supported by medical rationale, explaining the nature of the relationship between the diagnosed condition and appellant’s specific employment incident.9

In a case in which a preexisting condition involving the same part of the body is present and the issue of causal relationship therefore involves aggravation, acceleration, or precipitation,

2
Id.
3
F.H., Docket No. 18-0869 (issued January 29, 2020); J.P., Docket No. 19-0129 (issued April 26, 2019); Joe D. Cameron, 41 ECAB 153 (1989). 4 L.C., Docket No. 19-1301 (issued January 29, 2020); J.H., Docket No. 18-1637 (issued January 29, 2020); James E. Chadden, Sr., 40 ECAB 312 (1988). 5 P.A., Docket No. 18-0559 (issued January 29, 2020); K.M., Docket No. 15-1660 (issued September 16, 2016);
Delores C. Ellyett, 41 ECAB 992 (1990).
6
T.H., Docket No. 19-0599 (issued January 28, 2020); K.L., Docket No. 18-1029 (issued January 9, 2019); John J.
Carlone, 41 ECAB 354 (1989).
7
S.S., Docket No. 19-0688 (issued January 24, 2020); A.M., Docket No. 18-1748 (issued April 24, 2019); Robert G. Morris, 48 ECAB 238 (1996). 8 C.F., Docket No. 18-0791 (issued February 26, 2019); Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000).
9
Id.

5 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

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish a left wrist condition causally related to the accepted March 16, 2019 employment incident.

In her June 29, 2020 narrative, Dr. Williams opined that the March 16, 2019 employment incident was most likely the cause of the large flap of cartilaginous material floating in the wrist joint that she had identified during surgery. She indicated that appellant did not have any symptoms prior to March 16, 2019. Similarly, in her January 29, 2021 narrative, Dr. Tranchida opined within a reasonable degree of medical probability that the cartilage flap was caused by the employment incident. She also noted that appellant did not have any prior symptoms in the left wrist, and that the surgery by Dr. Williams had resolved his complaints. However, these reports do not provide medical rationale explaining the basis of their conclusory opinions regarding causal relationship between appellant’s left wrist condition and the March 16, 2019 employment incident.11 Consequently, the June 29, 2020 and January 29, 2021 opinions of Drs. Williams and Tranchida, respectively, are of limited probative value and insufficient to establish appellant’s claim.

In her August 16, 2019 report, Dr. Williams diagnosed a tear of the scapholunate ligament.
In the August 27, 2019 operative note, she diagnosed left wrist pain, carpal tunnel syndrome, Geissler grade 3 lunotriquetral ligament tear, triquetral chondromalacia, and loose body in joint. However, these reports do not contain an opinion on causation. The Board has held that medical evidence that does not offer an opinion regarding the cause of an employee’s condition is of no probative value on the issue of causal relationship.12 Therefore, Dr. Williams’ August 16 and 27, 2019 reports are also insufficient to establish appellant’s claim.

Similarly, in his May 13, 2019 report, Dr. Ahrenholz diagnosed carpal tunnel syndrome and Dr. Wolfer, in his July 18, 2019 report, found that appellant’s presentation was only partly consistent with carpal tunnel syndrome and that he may have a multi-factorial wrist/ligamentous injury, however, he did not address the issue of causation. As noted above, a report that does not offer an opinion on causation is of no probative value on the issue of causal relationship.13

The remaining medical evidence of record consists of diagnostic studies and notes by a nurse practitioner and a physical therapist. The Board has held that diagnostic studies, standing

10
Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3e (January 2013); J.L., Docket No. 20-0717 (issued October 15, 2020).
11
See W.L., Docket No. 20-1589 (issued August 26, 2021); T.M., Docket No. 08-975 (issued February 6, 2009) (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). 12 See L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., Docket No. 17-1549 (issued July 6, 2018).
13
Id.

6 alone, lack probative value as they do not address whether the employment incident caused any of the diagnosed conditions.14 The Board has also held that certain healthcare providers such as nurse practitioners and physical therapists are not considered “physician[s]” as defined under FECA.15 Consequently, their medical findings and/or opinions will not suffice for purposes of establishing entitlement to FECA benefits.16 As such, this evidence is insufficient to establish appellant’s claim.

As the medical evidence of record is insufficient to establish causal relationship between a left wrist condition and the accepted March 16, 2019 employment incident, appellant has not met his 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 has not met his burden of proof to establish a left wrist condition causally related to the accepted March 16, 2019 employment incident.

14
V.L., Docket No. 20-0884 (issued February 12, 2021); R.C., Docket No. 19-0376 (issued July 15, 2019).
15
Section 8101(2) provides that under FECA the term physician includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by the applicable state law. 5 U.S.C. § 8101(2); 20 C.F.R. § 10.5(t). See Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3a(1) (January 2013); David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006) (lay individuals such as physician assistants, nurses, and physical therapists are not competent to render a medical opinion under FECA); see also R.L., Docket No. 19-0440 (issued July 8, 2019) (nurse practitioners and physical therapists are not considered physicians under FECA). 16 D.P., Docket No. 19-1295 (issued March 16, 2020); G.S., Docket No. 18-1696 (issued March 26, 2019); see M.M., Docket No. 17-1641 (issued February 15, 2018); K.J., Docket No. 16-1805 (issued February 23, 2018); David P. Sawchuk, id.

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 ORDER

IT IS HEREBY ORDERED THAT the December 4, 2020 and March 26, 2021 decisions of the Office of Workers’ Compensation Programs are affirmed.

Issued: February 23, 2023
Washington, DC

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

Janice B. Askin, Judge
Employees’ Compensation Appeals Board

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

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