United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

R.R., Appellant 

and 

DEPARTMENT OF HOMELAND SECURITY, 

CUSTOMS & BORDER PATROL, Tucson, AZ, 

Employer 

__________________________________________ 

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Docket No. 14-1294 

Issued: October 1, 2014 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

PATRICIA HOWARD FITZGERALD, Judge 

ALEC J. KOROMILAS, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On May 15, 2014 appellant filed a timely appeal from a March 20, 2014 merit decision of 

the Office of Workers’ Compensation Programs (OWCP) which denied his traumatic injury 

claim. 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.2

 

 1

 5 U.S.C. § 8101 et seq.

2

 The Board notes that appellant submitted additional evidence following the March 20, 2014 decision. Since the 

Board’s jurisdiction is limited to evidence that was before OWCP at the time it issued its final decision, the Board 

may not consider this evidence for the first time on appeal. See 20 C.F.R. § 501.2(c); Sandra D. Pruitt, 57 ECAB 

126 (2005). Appellant may submit that evidence to OWCP along with a request for reconsideration. 
2

ISSUE 

The issue is whether appellant met his burden of proof to establish that his left shoulder 

condition was causally related to the August 5, 2013 employment incident. 

FACTUAL HISTORY 

On August 12, 2013 appellant, then a 56-year-old customs and border patrol officer, filed 

a traumatic injury claim alleging that on August 5, 2013 he experienced a sharp pain and large 

lump in his left shoulder when he tried to do a push-up after completing a physical fitness 

assessment.3 

In an August 8, 2013 report, Dr. Marc A. Kaplan, a family practitioner, related 

appellant’s complaints of left shoulder pain on-and-off for years. He noted that the most recent 

left shoulder pain occurred four days ago. Dr. Kaplan reported that appellant had a prior left 

shoulder dislocation and rotator cuff tear and had a left shoulder mass for years. Musculoskeletal 

examination revealed positive left shoulder apprehension test and tenderness to palpation of 

shoulder pass. Dr. Kaplan also observed left shoulder mass, back and joint pain, left shoulder 

pain, joint swelling and muscle weakness. He opined that appellant sustained pain in limb. 

Dr. Kaplan recommended x-rays of the left shoulder and referred appellant to an orthopedist for 

further evaluation. 

In an August 8, 2013 x-ray of the left shoulder, Dr. Steven Walsh, a Board-certified 

diagnostic radiologist, observed moderate degenerative changes on each side of the inferior 

acromioclavicular (AC) joint. He also noted 4x6 millimeter (mm) in diameter soft tissue 

calcification adjacent to the lateral cortex of the humeral head that was consistent with calcific 

tendinitis. Dr. Walsh diagnosed AC joint degenerative changes and calcific tendinitis. 

Appellant was provided an authorization for examination and/or treatment (Form CA-16) 

dated August 14, 2013 by Robert Munsey, his supervisor, for a left shoulder pulled muscle.4

 In 

the attending physician’s report (Part B), Dr. Kaplan stated that appellant experienced severe 

pain and moderate shoulder swelling after physical training. He noted that appellant sustained a 

shoulder injury about 20 years ago and had minor discomfort until a recent August 5, 2013 

injury. Dr. Kaplan diagnosed capsulitis of the left shoulder. He checked “yes” that he believed 

appellant’s condition was caused or aggravated by the described employment activity. 

Dr. Kaplan noted that appellant was partially disabled from August 5 to September 5, 2013 and 

recommended that appellant resume light work with restrictions of no lifting or weight bearing of 

the left arm. 

In a September 4, 2013 report, Dr. Kaplan noted appellant’s complaints of continued left 

shoulder pain. He reviewed appellant’s history and provided similar examination findings. 

 3

 Appellant filed a previous traumatic injury claim for a June 23, 2010 employment injury (File No. xxxxxx769). 

4

 The Board notes that a properly executed Form CA-16 creates a contractual obligation to pay for the cost of 

examination or treatment regardless of the action taken on the claim. See Tracey P. Spillane, 54 ECAB 608 (2003) 

and 20 C.F.R. § 10.300(c). 
3

Dr. Kaplan noted swollen bursa of the left shoulder and diagnosed occupational bursitis. In a 

September 4, 2013 duty status report, he advised appellant to return to light duty on 

September 4, 2013. 

In a September 12, 2013 narrative report, Dr. Jesse Wild, an orthopedic surgeon who 

specializes in sports medicine, stated that appellant was referred by Dr. Kaplan for evaluation of 

his left shoulder. He reported that appellant sustained an injury to his left shoulder on 

August 5, 2013 and complained of considerable pain with any overhead motion. Dr. Wild noted 

that plain radiographs were essentially negative. He reviewed appellant’s history and conducted 

an examination. Dr. Wild observed pain with forward flexion of the left shoulder, worse with 

abduction and pain with impingement testing. He reported that appellant’s AC joint was 

minimally tender. Biceps testing was plusminus. Dr. Wild stated that appellant had some 

perceived weakness and a lot of pain with resisted cuff testing. He opined that appellant had 

been in quite a bit of pain for over a month and was injured at work. In an attached work status 

note, Dr. Wild reported that appellant could work light duty as of September 12, 2013. 

In an October 9, 2013 magnetic resonance imaging (MRI) scan of the left shoulder, 

Dr. David P. Klein, a Board-certified diagnostic radiologist, observed mild degenerative callus 

formation and capsular hypertrophy at the AC joint and a moderate amount of degenerative 

marrow edema. He noted no rotator cuff tendon tear and intact biceps tendon and labrum. 

Dr. Klein diagnosed degenerative changes at the AC joint. 

In an October 22, 2013 report, Dr. Wild stated that appellant was reevaluated for his left 

shoulder after a recent injury at work. He noted that an MRI scan demonstrated a rather large 

mass in the subcutaneous region of the left shoulder, likely consistent with a lipoma. Dr. Wild 

reported that appellant’s rotator cuff appeared to be intact. He opined that the clinical scenario 

was more consistent with an adhesive capsulitis. Dr. Wild reviewed appellant’s history and 

conducted an examination. He observed a large mass along the top of the left shoulder. 

Dr. Wild also noted decreased range of motion and significant pain at the end range, consistent 

with a capsulitis. He recommended a limited MRI scan with and without contrast to further 

evaluate the mass and a short course of oral steroid. 

In a November 13, 2013 MRI scan of the left shoulder, Dr. Chad A. Kohl, a Boardcertified diagnostic radiologist, noted appellant’s complaints of traumatic left shoulder pain that 

radiated to the elbow. He observed a six centimeter (cm) encapsulated subcutaneous soft tissue 

lipoma about the shoulder and moderate AC joint arthrosis. Dr. Kohl also reported a four mm 

calcification about the posterior humeral head/rotator cuff footprint, suspected to be extruded 

from prior calcific tendinitis. He stated that there was a thinly-encapsulated subcutaneous fatty 

tumor with thin internal septations and no evidence of nodularity or signal intensity. 

In a November 19, 2013 report, Dr. Wild stated that an MRI scan revealed lipoma across 

the top of the shoulder and some AC joint arthrosis. He noted that these changes were consistent 

with a possible prior calcific tendinitis. Dr. Wild reviewed appellant’s history and conducted an 

examination. He observed some limitation to both active and passive motion. Dr. Wild 

suspected that this could be a mild adhesive capsulitis on top of his calcific tendinitis and AC 

arthrosis. He recommended a shoulder injection and more physical therapy. 
4

In a letter dated December 26, 2013, OWCP advised appellant that the evidence 

submitted was insufficient to establish his claim. It requested additional factual evidence to 

establish that the August 5, 2013 incident occurred as alleged and additional medical evidence to 

demonstrate that he sustained a diagnosed condition as a result of the alleged incident. 

In a December 19, 2013 report, Dr. Wild stated that appellant’s shoulder improved after 

the shoulder injection. Upon examination, he observed increased forward flexion and external 

rotation, still a significant discrepancy side to side. Dr. Wild opined that appellant’s symptoms 

were likely due to capsulitis, calcific tendinitis. He recommended continued physical therapy. 

On January 18, 2014 appellant responded to OWCP’s December 26, 2013 development 

letter. He stated that on April 5, 2013 he underwent a physical therapy (PT) assessment, which 

consisted of push-ups, sit-ups, pull-ups and 11⁄2 mile run. Appellant explained that after the 

push-ups he felt some discomfort on his arms and shoulder blades. He was able to complete one 

pull-up before he informed the instructor of his shoulder pain. Appellant experienced slight pain 

for the rest of the day and the following day when he trained with weapons. He went to the 

doctor’s office on August 9, 2013. Appellant reported that his prior shoulder problems occurred 

when he was in the U.S. Army. The injuries included a dislocation in the mid-1980s and a 

rotator cuff problem in the mid-1990s. 

In a decision dated March 20, 2014, OWCP denied appellant’s claim. It accepted that the 

August 5, 2013 incident occurred as alleged and that he sustained a diagnosed condition but 

denied his claim finding insufficient medical evidence to establish that his left shoulder condition 

was causally related to the accepted incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA5 has the burden of proof to establish the 

essential elements of his or her claim by the weight of the reliable, probative and substantial 

evidence6 including that he or she sustained an injury in the performance of duty and that any 

specific condition or disability for work for which he claims compensation is causally related to 

that employment injury.7

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.8

 

There are two components involved in establishing the fact of injury. First, the employee must 

submit sufficient evidence to establish that he actually experienced the employment incident at 

the time, place and in the manner alleged.9

 Second, the employee must submit evidence, 

 5

 5 U.S.C. §§ 8101-8193. 

6 J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968). 

7 G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989). 

8 S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005). 

9 Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968). 
5

generally only in the form of probative medical evidence, to establish that the employment 

incident caused a personal injury.10 An employee may establish that the employment incident 

occurred as alleged but fail to show that his disability or condition relates to the employment 

incident.11

Whether an employee sustained an injury in the performance of duty requires the 

submission of rationalized medical opinion evidence.12 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 the specific employment factors identified by 

the employee.13 The weight of the 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.14

ANALYSIS 

Appellant alleges that on August 5, 2013 he sustained an injury to his left shoulder after 

performing a push up while completing a PT assessment. The record reflects that appellant 

sustained previous left shoulder injuries when employed by the military. OWCP accepted that 

the August 5, 2013 incident occurred as alleged and that he was diagnosed with a left shoulder 

condition. However, it denied appellant’s claim finding insufficient medical evidence to 

establish that his left shoulder condition was causally related to the August 5, 2013 employment 

incident. The Board finds that he did not meet his burden of proof to establish his traumatic 

injury claim. 

Appellant was initially examined by Dr. Kaplan. In his reports dated August 8 to 

September 4, 2013, Dr. Kaplan reviewed appellant’s history and noted that he sustained prior left 

shoulder dislocation and rotator cuff tear a few years ago. Upon examination, he observed left 

shoulder mass, moderate joint swelling and swollen bursa. In an August 14, 2013 attending 

physician’s report, Dr. Kaplan noted a date-of-injury of August 5, 2013 and diagnosed capsulitis 

of the left shoulder. He checked “yes” that he believed appellant’s condition was caused or 

aggravated by the described employment activity. The Board finds that Dr. Kaplan provided an 

accurate date-of-injury and a diagnosis of left shoulder capsulitis. Dr. Kaplan did not, however, 

describe the employment incident or explain with medical rationale how the specific 

August 5, 2013 incident caused or contributed to appellant’s condition. The Board has held that 

a physician must provide a narrative description of the identified employment incident and a 

reasoned opinion on whether the employment incident described caused or contributed to 

 10 David Apgar, 57 ECAB 137 (2005); John J. Carlone, 41 ECAB 354 (1989). 

11 T.H., 59 ECAB 388 (2008); see also Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006). 

12 See J.Z., 58 ECAB 529 (2007); Paul E. Thams, 56 ECAB 503 (2005). 

13 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 465 (2005). 

14 James Mack, 43 ECAB 321 (1991). 
6

appellant’s diagnosed medical condition.15 Furthermore, although Dr. Kaplan checked “yes” 

regarding his belief of causal relationship, a physician’s opinion on causal relationship that 

consists only of checking “yes” to a form question, without explanation or rationale, is of 

diminished probative value and is insufficient to establish a claim.16 As Dr. Kaplan failed to 

adequately explain how appellant’s left shoulder condition was causally related to the 

August 5, 2013 employment incident and not an aggravation of a preexisting left shoulder 

condition, the Board finds that Dr. Kaplan’s reports are insufficient to establish appellant’s 

claim.17

Appellant also received medical treatment from Dr. Wild. In reports dated September 12 

to December 19, 2013, Dr. Wild noted that appellant sustained an injury to his shoulder on 

August 5, 2013. He reviewed appellant’s history and noted that an MRI scan revealed a rather 

large mass in the subcutaneous region of his left shoulder. Upon examination, Dr. Wild 

observed pain with forward flexion of the left shoulder, worse with abduction and pain with 

impingement testing. He reported that appellant’s biceps testing was plusminus and that his AC 

joint was minimally tender. Dr. Wild stated that appellant’s clinical scenario was consistent with 

adhesive capsulitis. In a November 19, 2013 report, he opined that appellant’s condition could 

be a mild adhesive capsulitis on top of his calcific tendinitis and AC arthrosis. Although 

Dr. Wild provided a diagnosis and noted a date-of-injury of August 5, 2013, he does not provide 

sufficient opinion or explanation regarding the cause of appellant’s left shoulder condition. The 

Board has found that 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.18 

Similarly, the additional diagnostic reports by Drs. Walsh, Klein, Kohl are also 

insufficient to establish appellant’s claim as none of the physicians provide any opinion on the 

cause of appellant’s left shoulder condition. 

On appeal, appellant did not provide any arguments. The Board has found that the issue 

of causal relationship is a medical question that must be established by probative medical 

opinion from a physician.19 Because appellant has not provided such medical evidence, the 

Board finds that he did not meet his burden of proof to establish his 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. 

 15 John W. Montoya, 54 ECAB 306 (2003). 

16 D.D., 57 ECAB 734, 738 (2006); Deborah L. Beatty, 54 ECAB 340 (2003). 

17 In cases 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 rationalized 

medical opinion which differentiates between the effects of the work-related injury or disease and the preexisting 

condition. See Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805(e) 

(January 2013). 

18 R.E., Docket No. 10-679 (issued November 16, 2010); K.W., 59 ECAB 271 (2007). 

19 W.W., Docket No. 09-1619 (issued June 2, 2010); David Apgar, 57 ECAB 137 (2005). 
7

CONCLUSION 

The Board finds that appellant did not meet his burden of proof to establish that his left 

shoulder condition was causally related to the August 5, 2013 employment incident. 

ORDER 

IT IS HEREBY ORDERED THAT the March 20, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: October 1, 2014 

Washington, DC 

 

 Patricia Howard Fitzgerald, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board