United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

T.G., Appellant 

and 

DEPARTMENT OF THE ARMY, 

INSTALLATION MANAGEMENT 

COMMAND, Fort Belvoir, VA, Employer 

__________________________________________ 

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Docket No. 15-1550 

Issued: November 5, 2015 

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 July 13, 2015 appellant filed a timely appeal from a May 27, 2015 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 his burden of proof to establish a work-related injury 

on March 10, 2015. 

FACTUAL HISTORY 

On March 11, 2015 appellant, then a 49-year-old maintenance mechanic leader, filed a 

traumatic injury claim (Form CA-1) alleging that he sustained an injury on March 10, 2015 when 

 1

 5 U.S.C. § 8101 et seq. 
2

he was carrying a large piece of plexiglass through a small doorway and tripped and fell to the 

ground. He stated that he twisted his right ankle, hurt his lower back, and bumped his head. 

Appellant stopped work on March 11, 2015 and received continuation of pay through 

April 24, 2015. The payment of a limited amount of medical expenses was administratively 

approved, but the merits of appellant’s claim were not formally considered at that time. On 

April 20, 2015 appellant filed a claim for compensation (Form CA-7) for the period April 25 to 

May 2, 2015.2

In a March 10, 2015 report, Dr. Yolanda C. Haywood, an attending Board-certified 

emergency medicine physician, noted that appellant reported that he tripped and fell while 

holding a piece of plexiglass on that date. Appellant complained of head, neck, back, ankle, and 

left shoulder pain. Dr. Haywood indicated that appellant’s computerized tomography (CT) scan 

and x-ray testing showed no evidence of internal injury. In the “diagnosis” portion of the report, 

she noted, “Accidental fall; acute back pain” and, in the “impression and plan” portion, she 

noted, “Acute back pain.” 

The findings of March 10, 2015 x-rays of appellant’s left shoulder showed no evidence of 

acute fracture or dislocation; March 10, 2015 x-rays of appellant’s left foot, left ankle, and 

lumbar spine showed no evidence of acute fracture.3 The findings of a March 10, 2015 CT scan 

of appellant’s cervical spine revealed no evidence of acute displaced fracture. The test revealed 

degenerative changes of the cervical spine including severe right facet arthropathy at C3-4 and 

moderate right facet arthropathy at C4-5. A March 10, 2015 CT scan of appellant’s brain 

showed a soft-tissue hematoma at the posterior vertex and no evidence of acute intracranial 

abnormality. 

In a March 26, 2015 report, Dr. Mudit Sharma, an attending Board-certified 

neurosurgeon, noted that appellant had been struggling with neck and back pain since a fall at 

work three weeks prior. Appellant reported that the pain did not radiate into his arms or legs. 

Dr. Sharma noted that appellant had a prior history of neck and back pain and sought medical 

treatment which included pain management services. He indicated that on examination he 

exhibited paraspinal muscle spasms in his neck and lower back area. Dr. Sharma discussed 

appellant’s cervical diagnostic testing and noted, “I would [like] to get better information on this 

patient with further imaging and work up. Specifically, I would like to get [a magnetic 

resonance imaging (MRI) scan] of the lumbar and cervical spine to get further treatment options 

for him.” 

In a March 26, 2015 note, Dr. Sharma noted, “Patient out of work from [March 17 to 

April 9, 2015].” In an April 8, 2015 note, Dr. Sharma indicated, “Out of work until surgery.” 

The findings of the April 7, 2015 MRI scan testing of appellant’s cervical spine revealed 

degenerative disc disease at multiple levels. 

 2

 On May 18, 2015 appellant filed a Form CA-7 for the period May 3 to 16, 2015. 

3

 There was a lucent lesion along the medial talar dome that was compatible with an osteochondral defect. 
3

In an April 23, 2015 letter, OWCP requested that appellant submit additional factual and 

medical evidence in support of his claim. 

Appellant submitted an April 8, 2015 report in which Dr. Sharma reported findings of his 

examination on that date. Dr. Sharma noted that he advised appellant that there might be a 

contribution to his problems from the C3-4 facet joint and that he would first address the anterior 

portion of the C3-4 disc. He indicated that, if appellant continued to have neck pain, then he 

might have to address his condition posteriorly with a C3-4 lateral mass construct. Dr. Sharma 

indicated that a posterior lumbar decompression would be contemplated and noted, “He needs to 

remain out of work until he is scheduled and then in approximately four to six weeks after the 

cervical standpoint.” 

Appellant resubmitted a portion of Dr. Haywood’s March 10, 2015 report and also 

submitted a March 10, 2015 report of the local fire and emergency medical services department 

in which an emergency medical technician described the care given to him on that date. 

By decision dated May 27, 2015, OWCP denied appellant’s claim because he did not 

submit sufficient medical evidence to establish that a work-related injury occurred on 

March 10, 2015. It explained that the reports submitted by him did not contain a rationalized 

medical opinion relating a specific diagnosed condition to that work incident. 

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 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.4

 These are the essential elements of each 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 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 he or she actually experienced the employment 

incident at the time, place, and in the manner alleged.6

 Second, the employee must submit 

evidence, in the form of medical evidence, to establish that the employment incident caused a 

personal injury.7 

 4 C.S., Docket No. 08-1585 (issued March 3, 2009); Elaine Pendleton, 40 ECAB 1143 (1989). 

5 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). 

6 Julie B. Hawkins, 38 ECAB 393 (1987). 

7 John J. Carlone, 41 ECAB 354 (1989). 
4

 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.8

ANALYSIS 

On March 11, 2015 appellant filed a traumatic injury claim alleging injury to his right 

ankle, lower back, and head on March 10, 2015 when he was carrying a large piece of plexiglass, 

tripped, and fell to the ground. The Board finds that appellant did not submit sufficient medical 

evidence to establish that a work-related injury occurred on March 10, 2015. Although OWCP 

has accepted the occurrence of the March 10, 2015 incident, the record does not contain 

rationalized medical opinion relating a specific diagnosed condition to that work incident. 

In a March 10, 2015 report, Dr. Haywood, an attending Board-certified emergency 

medicine physician, stated that appellant reported that he tripped and fell while holding a piece 

of plexiglass on that date. She indicated that appellant’s CT scan and x-ray testing showed no 

evidence of internal injury. In the “diagnosis” portion of the report, Dr. Haywood noted, 

“Accidental fall; acute back pain” and, in the “impression and plan” portion, she noted, “Acute 

back pain.” The submission of this report does not establish appellant’s claim for a work-related 

March 10, 2015 injury. Dr. Haywood did not provide a clear rationalized medical opinion 

relating a specific diagnosed condition to that work incident. The Board has held that medical 

evidence which does not offer any opinion regarding the cause of an employee’s condition is of 

limited probative value on the issue of causal relationship.9

In a March 26, 2015 report, Dr. Sharma, an attending Board-certified neurosurgeon, 

stated that appellant had been struggling with neck and back pain since a fall at work three weeks 

prior. He noted that appellant had a prior history of neck and back pain and sought medical 

treatment which included pain management services. Dr. Sharma indicated that he would like to 

obtain more diagnostic testing of appellant’s cervical spine. In a March 26, 2015 note, he noted, 

“Patient out of work from [March 17 to April 9, 2015.]” The Board notes that, although 

Dr. Sharma suggested that appellant had disability for a period, he did not diagnose any specific 

condition related to the March 10, 2015 work incident or otherwise identify the March 10, 2015 

work incident as necessitating the ostensible period of disability. 

Late in an April 8, 2015 report, Dr. Sharma discussed possible plans of treatment at the 

cervical level of C3-4. He indicated that a posterior lumbar decompression would be 

contemplated at that level and stated, “[Appellant] needs to remain out of work until he is 

scheduled and then in approximately four to six weeks after the cervical standpoint.” In an 

April 8, 2015 note, Dr. Sharma noted, “Out of work until surgery.” He did not diagnose any 

condition related to the March 10, 2015 work incident. Dr. Sharma did not provide any opinion 

that the possible future cervical surgery or any period of disability was related to the March 10, 

 8 See I.J., 59 ECAB 408 (2008); Donna Faye Cardwell, 41 ECAB 730 (1990). 

9 See Charles H. Tomaszewski, 39 ECAB 461 (1988). 
5

2015 work incident.10 For these reasons, the reports of Dr. Sharma are of limited probative value 

on the relevant issue of the present case. 

On appeal, appellant alleged that he actually sustained specific neck and low back 

injuries at work on March 10, 2015, but he did not explain how the medical evidence of record 

supported this argument. 

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 meet his burden of proof to establish a workrelated injury on March 10, 2015. 

ORDER 

IT IS HEREBY ORDERED THAT the May 27, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: November 5, 2015 

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 

 10 It is unclear from the record whether appellant actually underwent cervical surgery.