United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

K.D., Appellant 

and 

DEPARTMENT OF VETERANS AFFAIRS, 

TENNESSEE VALLEY HEALTHCARE 

SYSTEM, Nashville, TN, Employer 

__________________________________________ 

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Docket No. 14-1781 

Issued: August 14, 2015 

Appearances: Case Submitted on the Record

Alan J. Shapiro, Esq., for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On August 11, 2014 appellant, through counsel, filed a timely appeal of a July 2, 2014 

Office of Workers’ Compensation Programs’ (OWCP) merit decision. Pursuant to the Federal 

Employees’ Compensation Act1

 (FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has 

jurisdiction to consider the merits of the case. 

ISSUE 

The issue is whether appellant has met her burden of proof to establish that she sustained 

a traumatic injury on September 15, 2013 in the performance of duty. 

FACTUAL HISTORY 

On September 25, 2013 appellant, then a 59-year-old registered nurse, filed a traumatic 

injury claim alleging that she injured her neck, left arm, shoulders, and back catching a falling 

 1

 5 U.S.C. § 8101 et seq.
2

patient on September 15, 2013. The employing establishment submitted an incident report 

indicating that on September 15, 2013 appellant sustained a sprain/strain of the lower back 

assisting a falling patient. 

OWCP requested additional factual and medical evidence supporting appellant’s claim on 

October 7, 2013. In response, appellant submitted treatment notes from Dr. Jessica Folger, a 

physician Board-certified in emergency medicine, dated September 17, 2013. Dr. Folger noted 

appellant’s history of aiding a falling patient. She stated that appellant reported back and left 

wrist conditions as a result of placing her arms under the patient’s arms to lower him to the 

ground. Dr. Folger noted that appellant had previously undergone back surgery. She stated that 

appellant indicated that she had pain in the right mid-back with radiation into the right leg and 

groin. Dr. Folger found no associated signs or symptoms. Appellant demonstrated normal 

strength and normal sensation in all extremities. Dr. Folger diagnosed back pain, sciatica, and 

multiple strains including the wrist. 

Dr. Richard Smith, a Board-certified orthopedic surgeon, first examined appellant on 

September 24, 2013. He diagnosed sciatica, right wrist pain, cervicalgia, paresthesias, and 

thoracic spine pain. Dr. Smith described appellant’s employment incident of catching a falling 

patient with onset of pain in the neck and back. Appellant reported back pain radiating into her 

legs and wrist. On physical examination Dr. Smith found muscle spasms in the cervical, 

thoracic, and lumbar spines. Dr. Smith found an obscure motor weakness, normal reflexes, and 

sensation intact to light touch in all extremities. Appellant underwent a lumbar magnetic 

resonance imaging (MRI) scan on October 17, 2013 which demonstrated degenerative findings 

at L5-S1 with deformity of the right lamina suggesting previous surgery, spondylosis and disc 

bulge with facet arthropathy. On October 8, 2013 Dr. Smith examined appellant and noted that 

she reported pain radiating down her right leg and gait disturbance. He found that she had 

positive posterior tenderness in her spine with paravertebral muscle spasm and bilateral 

lumbosacral tenderness from L2-S1. Appellant’s left wrist was also swollen and tender. 

Dr. Smith completed notes on September 24 and October 8, 2013 indicating that she was totally 

disabled until October 23, 2013. 

Dr. Jacob P. Schwarz, a Board-certified neurosurgeon, examined appellant on 

November 11, 2013 and noted a history of lower back and bilateral lower extremity pain as well 

as L5-S1 hemilaminectomy. He stated that she attempted to catch a 250-pound patient who was 

falling to the ground on September 15, 2013. Dr. Schwarz reported that appellant experienced 

immediate pain in her lower back and legs. On physical examination he found no loss of 

strength or sensation in the lower extremities. Dr. Schwarz reviewed appellant’s MRI scan. He 

diagnosed lumbar radiculopathy, lumbar stenosis and lumbar disc displacement. 

By decision dated November 13, 2013, OWCP denied appellant’s claim on the grounds 

that she failed to submit sufficient medical opinion evidence to establish that a medical condition 

resulted from her accepted employment injury. It found that she had not submitted the necessary 

medical opinion evidence explaining how her employment incident caused, contributed, 

aggravated, or precipitated her diagnosed medical conditions. 

Appellant requested a review of the written record by an OWCP hearing representative 

on November 19, 2013. Dr. Smith completed a note on November 21, 2013 and stated that it 
3

was his opinion that appellant’s current back discomfort and radicular symptoms were due to her 

attempt to catch a patient on September 15, 2013. He stated that this incident resulted in a disc 

protrusion and sciatica-like syndrome. 

In a decision dated March 18, 2014, OWCP hearing representative found that the medical 

evidence was not sufficiently detailed and well reasoned to establish an injury-related condition 

resulting from the accepted September 15, 2013 work incident. 

Appellant, through counsel, requested reconsideration on May 15, 2014. He submitted 

additional medical evidence in support of the request. Dr. Vaughan A. Allen, a Board-certified 

neurosurgeon, examined appellant on December 30, 2012 and described appellant’s employment 

incident as lifting a patient. He stated that this resulted in the onset of severe low back pain, 

bilateral hip pain and left leg pain. Dr. Allen noted that he performed appellant’s previous back 

surgery and reviewed her MRI scan which demonstrated right paracentral disc protrusion and 

degenerative changes from L4-5 and L5-S1. He diagnosed lumbar strain and lumbar 

radiculopathy. Appellant provided a computerized tomography (CT) scan dated March 6, 2014 

which demonstrated severe left foraminal stenosis and moderate right foraminal stenosis at L5-

S1 due to marked disc degeneration. She also provided a lumbar myelogram of the same date 

which demonstrated mild central stenosis at T12-L1 and L4-5 as well as mild lateral recess 

stenosis on the right at L4-5. Appellant also resubmitted Dr. Smith’s November 21, 2013 note. 

By decision dated July 2, 2014, OWCP denied modification of its prior decisions finding 

that the medical evidence did not provide the necessary rationale to establish a causal 

relationship between appellant’s diagnosed back and wrist conditions and her accepted 

employment incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA2 has the burden of establishing the essential 

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

including the fact that the individual is an “employee of the United States” within the meaning of 

FECA and 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 or 

specific condition for which compensation is claimed is causally related to the employment 

injury.3

 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.4

OWCP defines a traumatic injury as, “[A] condition of the body caused by a specific 

event or incident, or series of events or incidents, within a single workday or shift. Such 

condition must be caused by external force, including stress or strain which is identifiable as to 

time and place of occurrence and member or function of the body affected.”5

 To determine 

 2

 5 U.S.C. §§ 8101-8193. 

3 Kathryn Haggerty, 45 ECAB 383, 388 (1994); Elaine Pendleton, 41 ECAB 1143 (1989). 

4 Victor J. Woodhams, 41 ECAB 345 (1989). 

5

 20 C.F.R. § 10.5(ee). 
4

whether a federal employee has sustained a traumatic injury in the performance of duty, it must 

first be determined whether a “fact of injury” has been established. 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 

sufficient evidence, generally only in the form a medical evidence, to establish that the 

employment incident caused a personal injury.7

A medical report is of limited probative value on a given medical question if it is 

unsupported by medical rationale.8

 Medical rationale includes a physician’s detailed opinion on 

the issue of whether there is a causal relationship between the claimant’s diagnosed condition 

and the implicated employment activity. The opinion of the physician must be based on a 

complete factual and medical background of the claim, 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 activity or factors identified by the 

claimant.9

ANALYSIS 

Appellant filed a claim alleging that, on September 15, 2013, she injured her back and 

left wrist catching a patient who was falling. The Board finds that the factual evidence 

establishes that the employment incident occurred as alleged. However, appellant must also 

submit sufficient rationalized medical opinion evidence to establish that a diagnosed condition 

was caused or aggravated by the accepted employment incident in order to establish her 

traumatic injury claim. In support of her claim, appellant submitted medical reports from several 

physicians. Dr. Folger initially examined appellant and reported a history of aiding a falling 

patient by placing her arms under the patient’s to lower him to the ground. She noted that 

appellant had pain in the right mid-back with radiation into the right leg and groin. Dr. Folger 

diagnosed back pain, sciatica, and multiple strains including the wrist. Her notes are not 

sufficient to meet appellant’s burden of proof in establishing a diagnosed condition resulting 

from her accepted employment incident. Dr. Folger did not provide a medical opinion that the 

employment incident resulted in the diagnosed conditions. Furthermore, appellant provided a 

diagnosis of back pain. The Board has held that the mere diagnosis of “pain” does not constitute 

the basis for payment of compensation.10 Without medical opinion evidence concluding that 

appellant’s September 2013 employment incident resulted in specific back and wrist conditions 

and explaining how these injuries occurred, Dr. Folger did not provide the necessary evidence to 

meet appellant’s burden of proof. 

 6 John J. Carlone, 41 ECAB 354 (1989). 

7 J.Z., 58 ECAB 529 (2007). 

8 T.F., 58 ECAB 128 (2006). 

9 A.D., 58 ECAB 149 (2006). 

10 Robert Broome, 55 ECAB 339 (2004). 
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On November 11, 2013 Dr. Schwarz examined appellant on November 11, 2013 and 

related that appellant attempted to catch a 250-pound patient who was falling to the ground on 

September 15, 2013. He diagnosed lumbar radiculopathy, lumbar stenosis and lumbar disc 

displacement. Dr. Allen completed a report dated December 30, 2013 and described appellant’s 

employment incident as lifting a patient. He stated that he had performed appellant’s previous 

back surgery. Dr. Allen diagnosed lumbar strain and lumbar radiculopathy. 

Like Dr. Folger, neither Dr. Schwarz nor Dr. Allen provided a statement opining that 

appellant’s diagnosed conditions were caused or aggravated by her employment incident. As 

these physicians did not offer the necessary medical opinion evidence, these reports are not 

sufficient to establish a causal relationship between appellant’s diagnosed condition and her 

employment and do not meet her burden of proof in establishing a traumatic injury claim. 

Appellant also sought treatment from Dr. Smith who examined her on September 24 and 

October 8, 2013. Dr. Smith described appellant’s employment incident of catching a falling 

patient with onset of pain in the neck and back. He diagnosed sciatica, right wrist pain, 

cervicalgia, paresthesias, and thoracic spine pain. This report also lacks the necessary opinion 

evidence to meet appellant’s burden of proof. While Dr. Smith described appellant’s 

employment September 2013 employment incident and diagnosed sciatica as well as paresthesias 

in addition to his diagnoses of pain, he did not offer an opinion that appellant’s employment 

incident caused or aggravated the diagnosed conditions. Without a medical opinion that the 

employment incident caused or contributed to appellant’s diagnosed conditions, this report is not 

sufficient to meet appellant’s burden of proof in establishing a traumatic injury claim. 

In his November 21, 2013 note, Dr. Smith stated that it was his opinion that appellant’s 

current back discomfort and radicular symptoms were due to her attempt to catch a patient on 

September 15, 2013. He stated that this incident resulted in a disc protrusion and sciatica-like 

syndrome. This report provides an opinion that appellant’s diagnosed condition of disc 

protrusion was the result of the September 15, 2013 employment incident. However, Dr. Smith 

did not provide any reasoning in support of his conclusion. Without medical rationale explaining 

how the September 15, 2013 caused or aggravated appellant’s current back condition this report 

is not sufficient to meet appellant’s burden of proof. As appellant had a preexisting back 

condition resulting in surgery, she must provide a comprehensive medical report including her 

prior medical history, a description of her September 15, 2013 employment incident, and medical 

reasoning describing how and why this incident resulted in her currently diagnosed back 

conditions. As Dr. Smith’s November 21, 2013 note lacks medical rationale in support of his 

opinion on causal relationship, this note does not meet appellant’s burden of proof in establishing 

her traumatic injury 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. 
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CONCLUSION 

The Board finds that appellant failed to submit the necessary rationalized medical opinion 

evidence to establish that her September 15, 2013 employment incident resulted in a traumatic 

injury. 

ORDER 

IT IS HEREBY ORDERED THAT the July 2, 2014 decision of the Office of Workers’ 

Compensation Programs is affirmed. 

Issued: August 14, 2015 

Washington, DC 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board