United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

D.W., Appellant 

and 

DEPARTMENT OF DEFENSE, DEFENSE 

COMMISSARY AGENCY, MCGUIRE AIR 

FORCE BASE, NJ, Employer 

__________________________________________ 

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Docket No. 13-1873 

Issued: March 13, 2014 

Appearances: Case Submitted on the Record

Thomas R. Uliase, Esq., for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

COLLEEN DUFFY KIKO, Judge 

ALEC J. KOROMILAS, Alternate Judge 

MICHAEL E. GROOM, Alternate Judge 

JURISDICTION 

On August 8, 2013 appellant, through her attorney, filed a timely appeal from a June 12, 

2013 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 that she developed 

bilateral carpal tunnel syndrome causally related to factors of her federal employment. 

FACTUAL HISTORY 

On September 27, 2012 appellant, then a 51-year-old sales associate and cashier, filed an 

occupational disease claim (Form CA-2) alleging carpal tunnel syndrome in the performance of 

 1

 5 U.S.C. § 8101 et seq. 
2

duty. She noted that her position as sales associate entailed lifting food items of 10 to 50 pounds. 

Appellant first became aware of her condition on February 2, 2010 and of its relationship to her 

employment in March 2010. She explained that she did not file her claim within 30 days after 

March 2010 because she had first visited a family physician for her condition and was unaware 

of the procedure for filing an occupational disease claim. 

On July 25, 2012 Dr. Daniel Mullin, a Board-certified emergency physician, stated that 

appellant had an overuse injury requiring her to follow up with a hand surgeon. He checked a 

box indicating that the injury was incurred in the line of duty. 

In a note dated July 30, 2012, Dr. Raymond Ragland III, a Board-certified orthopedic 

surgeon, diagnosed appellant with bilateral carpal tunnel syndrome. He stated that she could 

return to full duty on August 2, 2012. 

On October 24, 2012 OWCP requested additional factual and medical evidence from 

appellant. It noted that she had not substantiated the factual aspects of her claim and that the 

medical evidence was insufficient to support the causal relationship between her claimed 

condition and her employment activities. OWCP afforded appellant 30 days to submit additional 

evidence. 

In a note dated September 11, 2012, Dr. Harvey Licht, a Board-certified internist, 

released appellant to work without restrictions on September 12, 2012. 

By letter dated November 19, 2012, appellant’s representative stated that she would 

provide OWCP with medical evidence in support of her claim, but it would not be available until 

after the 30-day period had ended. She requested a 30-day extension of the period in order to 

submit medical evidence. 

By decision dated December 31, 2012, OWCP denied appellant’s claim. It found that she 

had failed to establish the factual elements of her claim, because she did not provide a detailed 

description of the work activities alleged to have caused her condition. OWCP also noted that 

appellant had not submitted sufficient medical evidence to establish that her condition was 

causally related to work activities. 

Appellant requested a hearing before an OWCP hearing representative on 

January 7, 2013. 

On April 15, 2010 Dr. Ragland diagnosed appellant with right de Quervain’s 

tenosynovitis. Appellant stated that she had lifted a 50-pound bag of dog food two weeks prior 

to her visit. She felt pain several days later in the radial aspect of her wrist. On examination of 

x-rays, Dr. Ragland noted no evidence of static deformity. On physical examination, he noted 

right carpometacarpal synovitis of the thumb. 

In a note dated October 1, 2010, Dr. Ragland diagnosed appellant with left trigger thumb. 

Appellant reported no discomfort in the right wrist, but described recent tenderness in the left 

thumb. On physical examination, Dr. Ragland noted tenderness over the A1 pulley with 

triggering of the left thumb with interphalangeal flexion and extension. 
3

In a note dated May 6, 2011, Dr. Ragland diagnosed appellant with right ring 

tenosynovitis and mild right carpal tunnel syndrome. On physical examination, he noted positive 

direct compression and a positive Tinel’s test at the right carpal canal. 

On July 30, 2012 Dr. Ragland reported that appellant’s right carpal tunnel syndrome had 

worsened. Appellant presented with mild paresthesias in the median nerve distribution of the left 

hand. Dr. Ragland noted that the Tinel’s sign was equivocal in the left carpal canal, but positive 

in the right carpal canal. Direct compression testing was positive bilaterally. Dr. Ragland 

referred appellant for a neurometric study to assess the median nerves bilaterally for peripheral 

compression. 

In a report dated October 10, 2012, Dr. Daniel J. Ragone, a Board-certified physician of 

physical medicine and rehabilitation, reported the results of a selective electromyogram and 

nerve conduction study. He stated an impression of mild to moderate right chronic carpal tunnel 

syndrome and early left chronic carpal tunnel syndrome. 

On October 17, 2012 Dr. Ragland diagnosed appellant with bilateral carpal tunnel 

syndrome. On physical examination, he noted positive bilateral results for Tinel’s sign and 

direct compression. Dr. Ragland stated that, to a reasonable degree of medical certainty, 

appellant’s bilateral carpal tunnel syndrome symptoms were work-related processes. He 

recommended an open right carpal tunnel release procedure. 

On November 7, 2012 Dr. Ragland stated that appellant’s bilateral carpal tunnel 

syndrome remained unchanged. He stated that a document containing a history of appellant’s 

condition and the results of a physical examination performed on November 7, 2012 was 

attached.2

In an operative report dated November 9, 2012, Dr. Ragland performed an endoscopic 

right carpal tunnel release procedure and an intervention of the left carpal canal. He noted that 

appellant had clinically and neurometrically demonstrated right and left carpal tunnel syndrome. 

In a note dated November 14, 2012, Dr. Ragland addressed appellant’s postsurgical 

neurovascular status and tendon function as intact. Appellant’s wound from surgery was clean 

and healing. On November 21, 2012 Dr. Ragland removed the surgical sutures from her wound. 

The hearing was held on April 10, 2013. Appellant described her history of employment 

at the employing establishment. She worked as a cashier and a dispatcher starting in 2005 and at 

the employing establishment commissary starting in 2008. Appellant stated that she did not have 

any particular problems with her hands before working in the latter position. As a cashier, her 

hands were constantly moving to scan groceries and she often had to lift heavy items to scan 

them. Appellant estimated that she scanned roughly 154,000 items per month. She also used a 

keyboard on the register to enter produce codes. Appellant stated that problems with her wrists 

started in 2010. She reported that, while she had a surgical procedure performed to correct her 

right wrist condition, her left wrist had developed similar symptoms and had only received an 

 2

 This document is not part of the case record. 
4

injection during the procedure. Appellant noted that she had no other medical conditions, 

injuries or hobbies involving her wrists. 

On April 18, 2013 Dr. Ragland stated that appellant had clinical and neurometric findings 

consistent with bilateral carpal tunnel syndrome. In reviewing appellant’s medical history, 

clinical and neurometric findings, her bilateral carpal tunnel syndrome was a work-related 

process and his opinion was rendered within a reasonable degree of medical certainty. 

By decision dated June 12, 2013, an OWCP’s hearing representative found that appellant 

had established her exposure to claimed work factors, but that her claim remained denied 

because she had not established a causal relationship between her diagnosed condition and 

exposure to work factors. 

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 is causally related to the 

employment injury.3 These are the essential elements of every compensation claim regardless of 

whether the claim is predicated on a traumatic injury or occupational disease.4 

To establish that an injury was sustained in the performance of duty in an occupational 

disease claim, a claimant must submit the following: (1) medical evidence establishing the 

presence or existence of the disease or condition for which compensation is claimed; (2) a factual 

statement identifying employment factors alleged to have caused or contributed to the presence 

or occurrence of the disease or condition; and (3) medical evidence establishing that the 

employment factors identified by the claimant were the proximate cause of the condition for 

which compensation is claimed or, stated differently, medical evidence establishing that the 

diagnosed condition is causally related to the employment factors identified by the claimant. 

The claimant has the burden of establishing by the weight of reliable, probative and 

substantial evidence that the condition for which compensation is sought is causally related to a 

specific employment incident or to specific conditions of employment.5

 An award of 

compensation may not be based on appellant’s belief of causal relationship. Neither the mere 

fact that a disease or condition manifests itself during a period of employment nor the belief that 

the disease or condition was caused or aggravated by employment factors or incidents is 

sufficient to establish a causal relationship.6

 3 Gary J. Watling, 52 ECAB 278, 279 (2001); Elaine Pendleton, 40 ECAB 1143, 1145 (1989). 

4 Michael E. Smith, 50 ECAB 313, 315 (1999). 

5 Roma A. Mortenson-Kindschi, 57 ECAB 418, 428 n.37 (2006); Katherine J. Friday, 47 ECAB 591, 594 (1996). 

6 P.K., Docket No. 08-2551 (issued June 2, 2009); Dennis M. Mascarenas, 49 ECAB 215, 218 (1997). 
5

Causal relationship is a medical issue and the medical evidence generally required to 

establish causal relationship is rationalized medical opinion evidence.7 Rationalized medical 

opinion evidence is medical evidence which includes a physician’s reasoned opinion on whether 

there is a causal relationship between the claimant’s diagnosed condition and the compensable 

employment factors. 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.8 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.9

ANALYSIS 

Appellant filed a claim alleging that she sustained bilateral carpal tunnel syndrome due to 

factors of her federal employment. OWCP accepted that she was a federal employee who filed a 

timely claim, that she had established exposure to claimed factors of employment and that a 

medical condition had been diagnosed, but found that she had not submitted sufficient 

rationalized medical evidence to establish that she sustained the claimed condition due to 

accepted work factors. 

The Board finds that appellant failed to submit sufficient rationalized medical evidence 

supporting that her carpal tunnel syndrome was caused by duties of her federal employment. 

Medical evidence that does not offer any opinion regarding the cause of an employee’s 

condition is of limited probative value on the issue of causal relationship.10 A note dated 

September 11, 2012 from Dr. Licht did not include opinions as to the cause of any diagnosed 

condition. The Board finds that this report is insufficient to meet appellant’s burden, as it did not 

provide any opinion on causal relationship. 

Appellant submitted two reports from Dr. Ragland containing opinions on causal 

relationship. In a note dated October 17, 2012, Dr. Ragland stated that, to a reasonable degree of 

medical certainty, her bilateral carpal tunnel syndrome symptoms were work-related processes. 

In a note dated April 18, 2013, he asserted that, in reviewing appellant’s history, clinical findings 

and neurometric findings, her bilateral carpal tunnel syndrome was a work-related process and 

that this opinion was rendered within a reasonable degree of medical certainty. In a July 25, 

2012 report, Dr. Mullin checked a box indicating that the injury was incurred in the line of duty. 

To be rationalized, the opinion of a physician must be based on a complete factual and 

medical background of the claimant, must be one of reasonable medical certainty and must be 

 7 Elizabeth H. Kramm (Leonard O. Kramm), 57 ECAB 117, 123 (2005). 

8 Leslie C. Moore, 52 ECAB 132, 134 (2000). 

9

 Jennifer Atkerson, 55 ECAB 317, 319 (2004); Naomi A. Lilly, 10 ECAB 560, 573 (1959). 

10 See Willie M. Miller, 53 ECAB 697, 701 n.9 (2002). 
6

supported by medical rationale explaining the nature of the relationship between the diagnosed 

condition and the specific employment factors identified by the claimant.11 Dr. Ragland’s 

reports provided diagnoses and statements of reasonable medical certainty, but failed to provide 

a detailed explanation as to how specific physical findings and results of diagnostic testing 

supported his opinion on causal relationship. He did not identify the specific employment 

factors alleged by appellant or explain how those activities caused her condition. Instead, 

Dr. Ragland merely referred generally to the history of her condition, physical findings and 

results of diagnostic testing. Dr. Mullin’s report is similarly deficient, as he checked a box 

indicating that appellant’s injury was incurred in the line of duty, without providing a complete 

factual and medical background, a statement of reasonable medical certainty or supportive 

medical rationale. The fact that a condition manifests itself or worsens during a period of 

employment12 or that work activities produce symptoms revelatory of an underlying condition 

does not raise an inference of causal relationship between a claimed condition and employment 

factors.13 The Board finds the reports of Drs. Ragland and Mullin insufficient to meet 

appellant’s burden, as they did not provide an adequate explanation regarding the cause of 

appellant’s bilateral carpal tunnel syndrome. 

On appeal, appellant’s representative argues that appellant has established a prima facie

case that should be remanded to OWCP for further development. OWCP’s procedure manual 

states that additional medical evidence may be obtained when a medical report establishes a 

prima facie claim, but fails to provide a sufficiently rationalized opinion on causal relationship.14 

In John J. Carlone, the Board found that when an uncontroverted inference of causal relationship 

is raised, but the reports establishing that, inference are insufficiently rationalized, OWCP is 

obligated to request further information from a claimant’s attending physician.15 However, the 

reports of Dr. Ragland do not raise an uncontroverted inference of causal relationship, because 

he did not attempt to describe how specific duties of appellant’s employment physiologically 

caused appellant’s claimed condition: instead, he asserted that causal relationship existed 

without any supporting rationale. Therefore, Dr. Ragland’s reports do not establish a prima facie 

claim that would require OWCP to obtain additional medical evidence. 

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 did not establish that she developed bilateral carpal tunnel 

syndrome causally related to factors of her federal employment 

 11 Leslie C. Moore, supra note 8. 

12 William Nimitz, Jr., 30 ECAB 567, 570 (1979). 

13 B.B., Docket No. 13-256 (issued August 13, 2013); Richard B. Cissel, 32 ECAB 1910, 1917 (1981). 

14 Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.5 (June 1995). 

15 John J. Carlone, 41 ECAB 354, 360 (1989). 
7

ORDER 

IT IS HEREBY ORDERED THAT the June 12, 2013 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: March 13, 2014 

Washington, DC 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 Michael E. Groom, Alternate Judge 

 Employees’ Compensation Appeals Board