United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

S.S., Appellant 

and 

DEPARTMENT OF JUSTICE, FEDERAL 

BUREAU OF INVESTIGATION, 

Los Angeles, CA, Employer 

__________________________________________ 

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Docket No. 14-211 

Issued: May 1, 2014 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

RICHARD J. DASCHBACH, Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

MICHAEL E. GROOM, Alternate Judge 

JURISDICTION 

On November 4, 2013 appellant filed a timely appeal from a June 26, 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 established a recurrence of a medical condition on May 3, 

2012 due to the accepted May 1, 2006 occupational injury. 

FACTUAL HISTORY 

On December 4, 2006 appellant, then a 43-year-old occupational health nurse, filed an 

occupational disease clam (Form CA-2) alleging a hand condition from use of her keyboard. She 

 1

 5 U.S.C. § 8101 et seq. 
2

first became aware of her condition on May 1, 2006, and of its relationship to her employment 

on August 14, 2006. On March 2, 2007 OWCP accepted appellant’s claim for bilateral radial 

styloid tenosynovitis, also known as de Quervain’s tenosynovitis. Appellant did not claim wage 

loss as a result of her condition. She received authorization for payment of medical procedures, 

including surgery and physical therapy. Appellant returned to full-time limited-duty work on 

May 22, 2008. 

In a form report dated June 7, 2007, Dr. George A. Macer, Jr., a Board-certified 

orthopedist, diagnosed appellant with carpal tunnel syndrome. In a report dated August 13, 

2007, Dr. Fred H. Batkin, Board-certified in physical medicine and rehabilitation, stated that an 

electromyogram/nerve conduction velocity (EMG/NCV) study of appellant’s bilateral upper 

extremities revealed normal sensory nerve conduction and bilateral median motor conduction 

with no evidence of median nerve neuropathy across the wrist and no evidence of peripheral 

polyneuropathy. 

In a February 20, 2008 record of a telephone conversation, appellant requested that carpal 

tunnel syndrome be added to her accepted conditions. On March 5, 2008 Dr. Macer called 

OWCP by telephone. OWCP informed him that appellant’s claim was not accepted for carpal 

tunnel syndrome or a shoulder condition; but he could provide a supplemental report discussing 

the diagnoses of carpal tunnel syndrome in light of the negative EMG/NCV test. Dr. Macer 

submitted additional reports listing a diagnosis of carpal tunnel syndrome, but did not provide 

the requested opinion addressing causal relation. On May 6, 2008 Dr. Macer stated that he 

believed nearly all of her symptoms were due to her accepted de Quervain’s tenosynovitis and 

recommended surgery, which was performed on May 19, 2008. 

In a report dated August 16, 2008, Dr. Sangarapillai Manoharan, Board-certified in 

emergency medicine, diagnosed appellant with bilateral carpal tunnel syndrome, status post left 

de Quervain’s tendon release and left shoulder tendinitis. Appellant reported that she developed 

pain in both wrists and hands in May 2006, and that her position involved prolonged writing, 

typing and data entry. On examination, Dr. Manoharan noted slight to moderate pain with 

flexion and extension of the left wrist and bilaterally negative Finklestein’s, Tinel’s and Phalen’s 

tests. He stated that scar tissue resulting from surgery to correct appellant’s left de Quervain’s 

tenosynovitis caused her symptoms. Dr. Manoharan referred her to a hand specialist and noted 

that her carpal tunnel syndrome appeared mostly on the left side. 

On August 20, 2008 Dr. Robert Sundstrom, a Board-certified orthopedic surgeon, 

diagnosed appellant with a superficial left radial nerve neuritis secondary to her radial wrist 

surgery and probable left carpal tunnel syndrome. While the radial neuritis was related to the 

previous surgery, the carpal tunnel syndrome “may have been present to some degree before the 

de Quervain’s surgery” and “was more likely than not aggravated by the surgery and had been a 

result of previous work experience.” On examination, he noted a positive Finklestein’s test and a 

positive Phalen’s test. Dr. Sundstrom reviewed appellant’s history of injury, stating that she had 

worked at the employing establishment for three years in a position that involved typing and 

prolonged writing and data entry. He noted that in May 2006, she developed pain in both wrists 

and hands without any acute event. Appellant’s pain was aggravated by typing and writing 

activity at work. Dr. Sundstrom stated that on initial discussion regarding her carpal tunnel 

syndrome, appellant described only numbness on the volar aspect of her thumb, but that, after he 
3

informed her about typical carpal tunnel syndromes, she became aware of some parasthesias in 

the index, long and radial ring fingers. 

In a diagnostic report dated October 9, 2008, Dr. Arnold S. Rappoport, a Board-certified 

radiologist, obtained a magnetic resonance imaging (MRI) scan of appellant’s left wrist. He 

noted no abnormality in the flexor and extensor tendons; normal components of the carpal 

tunnel, including normal extensor pollicis brevis and abductor pollicis longus tendons; no 

evidence of increased signal, thickening, or abnormality in the surrounding soft tissue of these 

tendons; articulations within normal limits; normal intracarpal ligaments; and a normal triangular 

fibrocartilaginous complex. Dr. Rappoport concluded that no abnormality had been 

demonstrated. 

In a progress report dated November 14, 2008, Dr. Manoharan reviewed the results of a 

bilateral bone scan study and the MRI scan of appellant’s left hand. The bone scan study 

revealed no evidence for reflex sympathetic dystrophy and the MRI scan was normal. 

Dr. Manoharan stated that most of appellant’s bilateral carpal tunnel syndromes were localized 

over the left wrist, particularly over the site where she had a surgical excision for her 

de Quervain’s tendinitis. He recommended continuing modified duty under the prior restrictions. 

On January 16, 2009 Dr. Joshua Sussman, Board-certified in physical medicine and 

rehabilitation, conducted an EMG/NCV study of appellant’s hands and wrists. He stated that 

appellant’s study was abnormal, finding evidence suggestive of a right ulnar motor neuropathy 

with relative slowing across the elbow. 

On April 9, 2009 Dr. Manoharan reviewed appellant’s history of injury, stating that she 

worked as a registered nurse at the employing establishment. Her usual duties involved 

prolonged writing, typing and data entry. Dr. Manoharan noted that she had developed pain in 

the wrists and hands in May 2006 and was diagnosed with bilateral carpal tunnel syndrome and 

left de Quervain’s tenosynovitis. She underwent surgery for her left de Quervain’s tenosynovitis 

and, following surgery, she noticed increased pain as well as weakness and numbness in her left 

hand and thumb. Dr. Manoharan diagnosed bilateral carpal tunnel syndrome, status post left 

de Quervain’s tendon release and left shoulder tendinitis. He treated appellant by prescribing 

bilateral wrist braces and medication for the surgical incision site. Dr. Manoharan stated that her 

pain was mainly coming from the surgical site of her left de Quervain’s tendon release. Even 

though she had carpal tunnel syndrome, appellant’s pain was mainly confined and localized to 

the left thumb. Dr. Manoharan recommended a bone scan to rule out reflex sympathetic 

dystrophy. The study showed findings consistent with a prior surgery to the left wrist and 

subsequent dystrophic changes involving only the left thumb. On referral to Dr. Sundstrom, he 

found that appellant had superficial left radial nerve neuritis secondary to radial wrist surgery, 

and recommended physical therapy. Her symptoms slowly ameliorated and appellant worked 

modified duty. Dr. Manoharan stated that appellant had slight pain at rest bilaterally at the wrist 

and hand, and that, after prolonged movements, it would increase to moderate pain, which was 

mostly localized over the left thumb. On examination, he noted a positive Tinel’s sign bilaterally 

and a positive Finkelstein’s sign on the left. Dr. Manoharan stated that “[B]ased on the history, 

measureable objective findings, review of the medical records, it is the opinion of this examiner 

more likely than not [that] the repetitive/repetitive cumulative trauma that the patient sustained at 

work is the cause of her symptoms in both wrists/hands.” Dr. Manoharan recommended work 
4

restrictions of no lifting over 30 to 40 pounds, no prolonged gripping or grasping, and no typing 

or data entry for more than 45 minutes every hour. 

On May 3, 2012 Dr. Manoharan noted that appellant complained of thumb pain, neuritis 

and bilateral carpal tunnel syndrome. He requested authorization for occupational therapy for 

appellant’s wrists and an ergonomic work station evaluation. 

In a report dated May 24, 2012, Dr. Manoharan stated that appellant was seen for 

complaint of slight dull intermittent bilateral wrist pain. On examination of the wrists and hands, 

he noted tenderness bilaterally. Appellant was referred to occupational therapy and attended for 

one session. Dr. Manoharan noted that she had reached maximum medical improvement as of 

May 24, 2012 and that she had permanent work restrictions. 

On June 19, 2012 Dr. Manoharan noted that appellant’s slight dull intermittent bilateral 

wrist pain improved with rest and medication and worsened with typing. Appellant had other 

symptoms, such as numbness and tingling of the first three fingers. Dr. Manoharan advised her 

to continue with a wrist brace. 

 On September 5, 2012 Dr. Manoharan noted that appellant had completed the treatment 

modalities of taking nonsteroidal anti-inflammatory drugs, physical therapy and bracing, with 

good improvement upon each. He observed no tenderness to the wrists or hands upon physical 

examination. Dr. Manoharan released appellant from care as of that date and noted that she 

continued with her permanent work restrictions. He stated that she had reached maximum 

medical improvement as of September 5, 2012, diagnosing her with bilateral carpal tunnel 

syndrome, aftercare following surgery for left de Quervain’s tenosynovitis and resolved bilateral 

wrist pain. 

 Appellant submitted October 5, 2012 requests for authorization for durable medical 

equipment and further physical therapy for treatment of her bilateral radial styloid tenosynovitis, 

bilateral carpal tunnel syndrome and limb pain. The dates of service were from August 13 

through September 4, 2012. Appellant had also submitted requests for authorization of physical 

therapy on June 22, 2012, noting a diagnoses of bilateral carpal tunnel syndrome and wrist pain, 

and on August 15, 2012, noting a diagnosis of carpal tunnel syndrome. Payment for physical 

therapy on appellant’s claim had last been authorized on February 6, 2009. 

On May 17, 2013 appellant filed a claim for recurrence of medical condition. She noted 

that she continued to perform her regular duties after surgery because she was the only nurse at 

the employing establishment. The employing establishment noted that appellant was removed 

from its rolls effective February 20, 2013. Appellant did not claim wage loss and stated that she 

had not worked since leaving the employing establishment. 

By letter dated May 23, 2013, OWCP requested additional medical evidence from 

appellant to support her claim for a recurrence of her medical condition. It noted that the 

evidence she had submitted was insufficient to support her claim because it contained no medical 

explanation of how her diagnosis of bilateral carpal tunnel syndrome was the result of a material 

change or worsening of her accepted bilateral radial tenosynovitis. 
5

In a report dated June 12, 2013, Dr. Manoharan noted that appellant had been declared 

permanent and stationary as to her bilateral wrist condition. Appellant’s diagnoses at the time of 

the declaration were carpal tunnel syndrome and wrist pain. Dr. Manoharan noted that she had a 

flare-up of her symptoms of carpal tunnel syndrome, and noted tenderness of the wrists and 

hands bilaterally. He stated that appellant had intermittent slight dull pain in her wrists 

bilaterally. Dr. Manoharan diagnosed her with bilateral carpal tunnel syndrome and wrist pain 

and released her from his care. 

By decision dated June 26, 2013, OWCP denied appellant’s claim for a recurrence of her 

medical condition. It noted that she had not provided a medical report from a physician 

explaining how her carpal tunnel syndrome was related to her accepted condition of radial 

styloid tenosynovitis. 

LEGAL PRECEDENT 

A claimant has the burden of establishing that she sustained a recurrence of a medical 

condition2

 that is causally related to her accepted employment injury. To meet her burden, she 

must furnish medical evidence from a physician who, on the basis of a complete and accurate 

factual and medical history, concludes that the condition is causally related to the employment 

injury and supports that conclusion with sound medical rationale.3

 Where no such rationale is 

present, the medical evidence is of diminished probative value.4

OWCP regulations define a recurrence of medical condition as the documented need for 

further medical treatment after release from treatment of the accepted condition when there is no 

work stoppage. Continued treatment for the original condition is not considered a renewed need 

for medical care, nor is examination without treatment.5

OWCP’s procedure manual provides that, after 90 days of release from medical care 

(based on the physician’s statement or instruction to return as needed (PRN), or computed by the 

claims examiner from the date of last examination), a claimant is responsible for submitting an 

attending physician’s report which contains a description of the objective findings and supports 

causal relationship between the claimant’s current condition and the previously accepted work 

injury.6

 2

 Recurrence of medical condition means a documented need for further medical treatment after release from 

treatment for the accepted condition or injury when there is no accompanying work stoppage. Continuous treatment 

for the original condition or injury is not considered a need for further medical treatment after release from 

treatment, nor is an examination without treatment. 20 C.F.R. § 10.5(y). 

3 Ronald A. Eldridge, 53 ECAB 218 (2001). 

4 Mary A. Ceglia, 55 ECAB 626 (2004); Albert C. Brown, 52 ECAB 152 (2000). 

5

 20 C.F.R. § 10.5(y). 

6

 Federal (FECA) Procedure Manual, Part 2 -- Claims, Recurrences, Chapter 2.1500.5(b) (September 2003). The 

procedure manual provides, with certain exceptions, that, within 90 days of release from medical care (as stated by 

the physician or computed from the date of last examination or the physician’s instruction to return PRN), a claims 

examiner may accept the attending physician’s statement supporting causal relationship between appellant’s current 

condition and the accepted condition, even if the statement contains no rationale. Id. at Chapter 2.1500.5(a). 
6

ANALYSIS 

The Board finds that appellant has not established that she sustained a recurrence of her 

medical condition. OWCP accepted her occupational disease claim for bilateral radial styloid 

tenosynovitis on March 2, 2007, for which she underwent surgery. Appellant has claimed 

compensation for medical treatment of her condition. She failed, however, to submit sufficient 

rationalized medical evidence to establish that she required further medical treatment for her 

employment-related condition. 

In a report dated September 5, 2012, Dr. Manoharan stated that he released appellant 

from care as of that date but that she should continue with her permanent work restrictions. He 

listed the diagnoses of bilateral carpal tunnel syndrome, aftercare following surgery for left 

de Quervain’s tenosynovitis and resolved bilateral wrist pain. Dr. Manoharan noted that 

appellant had completed the recommended treatment modalities of taking nonsteroidal antiinflammatory drugs, physical therapy and bracing, with good improvement upon each. 

Appellant’s last physical therapy visit was on September 4, 2012, according to an authorization 

request dated October 5, 2012. There is no evidence of record documenting that she received 

medical treatment for her accepted condition between September 5, 2012, the date she was 

released from Dr. Manoharan’s care, and June 12, 2013, when she was again examined by 

Dr. Manoharan. Appellant’s examination on June 12, 2013 was more than 90 days after her 

release from medical care. Therefore, she must submit an attending physician’s report on the 

causal relationship of her current medical condition to her accepted bilateral radial styloid 

tenosynovitis.7

 Appellant had the burden of submitting sufficient medical evidence to document 

the need for further medical treatment.8

 She did not submit such evidence as required and failed 

to establish a need for continuing medical treatment.9

Dr. Manoharan’s reports are insufficient to establish appellant’s claim. In a report dated 

June 12, 2013, he diagnosed her with carpal tunnel syndrome and wrist pain, noting that he had 

previously declared her condition permanent and stationary. Dr. Manoharan noted that appellant 

had a flare-up of her symptoms of carpal tunnel syndrome, and noted tenderness of the wrists 

and hands bilaterally. He stated that she had intermittent slight dull pain in her wrists bilaterally. 

This is the only report of record submitted by Dr. Manoharan after he released appellant from his 

care on September 5, 2012. It does not contain an opinion addressing the causal relationship 

between appellant’s current condition or need for continuing medical treatment and her accepted 

injury. It does not contain any reference to appellant’s accepted condition. Medical evidence 

that does not offer any opinion regarding the cause of an employee’s condition is of limited 

probative value.10 The Board notes that appellant’s claim was not accepted for carpal tunnel 

syndrome, but for radial styloid tenosynovitis, or de Quervain’s tenosynovitis. To establish a 

recurrence, appellant must submit a rationalized medical opinion addressing the causal 

 7

 Federal (FECA) Procedure Manual, supra note 6. 

8 Supra note 5. 

9 See J.F., 58 ECAB 331 (2006). 

10 Michael E. Smith, 50 ECAB 313 (1999). 
7

relationship between her current condition and her accepted condition of radial styloid 

tenosynovitis. 

Appellant also submitted notes from physical therapists. Physical therapy notes do not 

constitute probative medical evidence, as a physical therapist is not a “physician” under FECA.11 

The reports of diagnostic studies, magnetic resonance imaging and x-rays, do not provide any 

opinion as to the cause of appellant’s condition. These are also of diminished probative value 

and are insufficient to establish her claim.12

The medical evidence of record must be supported by rationalized medical evidence 

explaining the nature of the relationship between appellant’s current condition and her accepted 

injury.13 An award of compensation may not be based on surmise, conjecture, speculation or 

upon appellant’s own belief that there was a causal relationship between her claimed condition 

and her employment.14 The Board finds that OWCP properly denied appellant’s claim, as she 

did not meet her burden of proof to establish that she sustained a recurrence of a medical 

condition. 

On appeal, appellant contends that OWCP misunderstood the nature of her claim, and 

that she was not claiming monetary compensation for time lost from work, but rather only for 

additional medical treatment in the form of physical therapy. As noted, however, the medical 

evidence submitted to the record is not sufficient to establish that her need for physical therapy 

on or after May 3, 2012 is due to residuals of her accepted de Quervain’s tenosynovitis or the 

surgery performed in 2008. 

Section 8103(a) of FECA states in pertinent part: The United States shall furnish to an 

employee who is injured while in the performance of duty, the services, appliances and supplies 

prescribed or recommended by a qualified physician, which the Secretary of Labor considers 

likely to cure, give relief, reduce the degree or the period of disability or aid in lessening the 

amount of the monthly compensation.15 The Board has found that OWCP has great discretion in 

determining whether a particular type of treatment is likely to cure or give relief.16 The only 

 11 Section 8101(2) of FECA provides as follows: (2) “physician includes surgeons, podiatrists, dentists, clinical 

psychologists, optometrists, chiropractors and osteopathic practitioners within the scope of their practice as defined 

by State law.” 

12 See Mary E. Marshall, 56 ECAB 420 (2005). 

13 While the medical opinion of a physician supporting causal relationship does not have to reduce the cause or 

etiology of a disease or condition to an absolute certainty, neither can such opinion be speculative or equivocal. The 

opinion of a physician supporting causal relationship must be one of reasonable medical certainty that the condition 

for which compensation is claimed is causally related to federal employment, and such relationship must be 

supported with affirmative evidence, explained by medical rationale and be based upon a complete and accurate 

medical and factual background of the claimant. See Thomas A. Faber, 50 ECAB 566 (1999); Samuel Senkow, 

50 ECAB 370 (1999). 

14 Patricia J. Glenn, 53 ECAB 159 (2001). 

15 5 U.S.C. § 8103. 

16 Vicky C. Randall, 51 ECAB 357 (2000). 
8

limitation on OWCP’s authority is that of reasonableness.17 Abuse of discretion is generally 

shown through proof of manifest error, clearly unreasonable exercise of judgment, or actions 

taken which are contrary to both logic and probable deductions from established facts. It is not 

enough to merely show that the evidence could be construed so as to produce a contrary factual 

conclusion.18 In order to be entitled to reimbursement of medical expenses, it must be shown 

that the expenditures were incurred for treatment of the effects of the employment-related injury 

or condition.19 Proof of causal relationship in a case such as this must include supporting 

rationalized medical evidence.20

The Board finds that OWCP did not abuse its discretion in denying authorization for 

physical therapy. Appellant did not establish that the expenditures claimed were incurred for 

treatment of the residuals arising from her accepted condition or surgery. OWCP did not abuse 

its discretion by denying authorization for payment of physical therapy. 

The Board notes that appellant submitted evidence after the issuance of the June 26, 2013 

decision. The Board lacks jurisdiction to review evidence for the first time on appeal.21 

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 her burden of proof to establish that she 

sustained a recurrence of a medical condition causally related to her accepted injury. 

 17 Lecil E. Stevens, 49 ECAB 673, 675 (1998). 

18 Rosa Lee Jones, 36 ECAB 679 (1985). 

19 Bertha L. Arnold, 38 ECAB 282, 284 (1986). 

20 Zane H. Cassell, 32 ECAB 1537, 1540-41 (1981); John E. Benton, 15 ECAB 48, 49 (1963). 

21 20 C.F.R. § 501.2(c). 
9

ORDER 

IT IS HEREBY ORDERED THAT the June 26, 2013 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: May 1, 2014 

Washington, DC 

 

 Richard J. Daschbach, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 Michael E. Groom, Alternate Judge 

 Employees’ Compensation Appeals Board