United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

S.R., Appellant 

and 

DEPARTMENT OF THE INTERIOR, 

BR-REGULAR EMPLOYEE FUNCTIONS, 

Billings, MT, Employer 

__________________________________________ 

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Docket No. 14-1103 

Issued: September 4, 2014 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

COLLEEN DUFFY KIKO, Judge 

PATRICIA HOWARD FITZGERALD, Judge 

MICHAEL E. GROOM, Alternate Judge 

JURISDICTION 

On April 15, 2014 appellant filed a timely appeal from a February 25, 2014 schedule 

award 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 sustained more than a seven percent permanent 

impairment of the right upper extremity for which he received a schedule award. 

FACTUAL HISTORY 

On November 11, 2011 appellant, then a 40-year-old drill rig operator, sustained a right 

shoulder injury from unloading a box of wall bits. On December 9, 2011 OWCP accepted the 

 1

 5 U.S.C. § 8101 et seq.
2

claim for tears of the right shoulder supraspinatus and infraspinatus tendons and dislocation of 

the bicep. 

On December 15, 2011 appellant underwent open repair of the supraspinatus and upper 

border subscapularis and infraspinatus tendons with bicep tenodesis and athroscopic subacromial 

decompression. On October 23, 2012 he underwent subacromial smoothing, smooth and move, 

removal of multiple sutures and buried suture anchors with resection of a prominent tuberosity 

bone and manipulation under anesthesia. 

In an April 5, 2013 medical report, Dr. John Petrisko, Board-certified in occupational 

medicine, diagnosed appellant with an irreparable right shoulder rotator cuff repair with range of 

motion deficits. He provided range of motion measurements, noted reduced range of motion and 

opined that maximum medical improvement (MMI) had been reached. Using the range of 

motion method under the sixth edition of the American Medical Association, Guides to the 

Evaluation of Permanent Impairment (A.M.A., Guides),2

 Dr. Petrisko rated 10 percent 

impairment of the upper right extremity based on Table 15-343 or a 6 percent whole person 

impairment. He noted utilizing Figure 15-28, Figure 15-29 and Figure 15-30 of the A.M.A., 

Guides.4 Dr. Petrisko did not provide calculations demonstrating how he reached his impairment 

rating. 

On January 22, 2014 appellant filed a claim for a schedule award (Form CA-7). 

On January 27, 2014 OWCP routed Dr. Petrisko’s report, a statement of accepted facts 

(SOAF) and the case file to Dr. Morley Slutsky, Board-certified in occupational medicine and an 

OWCP district medical adviser (DMA). In a February 19, 2014 report, Dr. Slutsky stated that 

appellant reached MMI of the upper right extremity on January 21, 2014. He noted that 

appellant’s impairment rating should be calculated based on the preferred diagnosis-based 

impairment method rather than Dr. Petrisko’s range of motion method which conform to the 

range of motion protocols at Section 15.7, page 464. 

Using Table 15-5, Shoulder Regional Grid, of the sixth edition of the A.M.A., Guides, 

Dr. Slutsky found that appellant had the diagnosis-based condition of full thickness rotator cuff 

tear with residual dysfunction and, therefore, fell under the class 1 default value of five percent 

impairment.5

 Applying Table 15-7, he noted that appellant had a grade modifier of 1 for 

Functional History (GMFH), the ability to perform self-care activities independently with mild 

problems of pain and symptoms with strenuous activity.6

 With respect to Physical Examination 

(GMPE), Dr. Slutsky noted that Dr. Petrisko only documented one motion per joint movement 

which was not consistent with Section 15.7, Range of Motion Impairment, of the A.M.A., 

 2

 A.M.A., Guides. 

3 Id. at 475. 

4 Id. at 475-76. 

5 Id. at 403. 

6 Id. at 406. 
3

Guides.

7

 As no other objective deficits were documented, he assigned a grade modifier of 0 for 

GMPE.8

 A grade modifier of 4 was assigned for Clinical Studies (GMCS) (diagnoses confirmed 

by diagnostic testing and moderate pathology).9 Applying the net adjustment formula, 

Dr. Slutsky subtracted 1, the numerical value of the class, from the numerical value of the grade 

modifier for each component (functional history, physical examination and clinical studies) and 

then added those values, resulting in a net adjustment of 2 ((1-1) + (0-1) + (4-1)).10 He noted 

that application of the net adjustment formula meant that movement was warranted two places to 

the right of class 1 default value grade C to grade E based on Table 15-5. Therefore, the 

diagnosis-based impairment rating for appellant’s right rotator cuff, full thickness tear with 

residual dysfunction yielded a seven percent impairment of the upper right extremity.11 

By decision dated February 25, 2014, OWCP granted appellant a schedule award claim 

for seven percent permanent impairment of the right arm. The date of maximum medical 

improvement was noted as January 21, 2014. The award covered a period of 21.84 weeks from 

January 21 to June 22, 2014. 

LEGAL PRECEDENT 

The schedule award provision of FECA and its implementing regulations set forth the 

number of weeks of compensation payable to employees sustaining permanent impairment from 

loss or loss of use of scheduled members or functions of the body.12 However, FECA does not 

specify the manner in which the percentage of loss shall be determined. For consistent results 

and to ensure equal justice under the law to all claimants, good administrative practice 

necessitates the use of a single set of tables so that there may be uniform standards applicable to 

all claimants. The A.M.A., Guides has been adopted by the implementing regulations as the 

appropriate standard for evaluating schedule losses.13

The A.M.A., Guides provide a diagnosis-based method of evaluation utilizing the World 

Health Organization’s International Classification of Functioning, Disability and Health (ICF).14 

In determining impairment for the upper extremities under the sixth edition of the A.M.A., 

Guides, an evaluator must establish the appropriate diagnosis for each part of the upper extremity 

to be rated. After the class of diagnosis (CDX) is determined for the diagnosed condition 

(including identification of a default grade value), the net adjustment formula is applied using the 

 7 Id. at 459. 

8 Id. at 408. 

9 Id. at 410. 

10 Id. at 411. 

11 Supra note 5. 

12 5 U.S.C. § 8107; 20 C.F.R. § 10.404. 

13 K.H., Docket No. 09-341 (issued December 30, 2011). For decisions issued after May 1, 2009, the sixth 

edition will be applied. B.M., Docket No. 09-2231 (issued May 14, 2010). 

14 A.M.A., Guides, supra note 2 at 3, section 1.3, The ICF: A Contemporary Model of Disablement. 
4

grade modifier for Functional History, grade modifier for Physical Examination and grade 

modifier for Clinical Studies.15 The net adjustment formula is (GMFH - CDX) + (GMPE - 

CDX) + (GMCS - CDX).16 Under Chapter 2.3, evaluators are directed to provide reasons for 

their impairment rating choices, including choices of diagnoses from regional grids and 

calculations of modifier scores.17

In the sixth edition, diagnosis-based impairment (DBI) is the primary method of 

evaluation for the upper extremity. A grid listing relevant diagnoses is provided for each region 

of the upper extremity: the digit region, the wrist region, the elbow region and the shoulder 

region. A regional impairment will be defined by class and grade. The class is determined first 

by using the corresponding regional grid. The grade is initially assigned the default value for 

that class. This value may be adjusted slightly using nonkey grade modifiers such as functional 

history, physical examination and clinical studies.18

The A.M.A., Guides at Section 15.7 provides: 

“Range of motion should be measured after a warm up, in which the individual 

moves the joint through its maximum range of motion at least [three] times. The 

range of motion examination is then performed by recording the active 

measurements from [three] separate range of motion efforts. All measurements 

should fall within 10 [degrees] of the mean of these three measurements. The 

maximum observed measurement is used to determine the range of motion 

impairment.”19

OWCP’s procedures provide that, after obtaining all necessary medical evidence, the file 

should be routed to an OWCP medical adviser for an opinion concerning the nature and 

percentage of impairment in accordance with the A.M.A., Guides, with the medical adviser 

providing rationale for the percentage of impairment specified.20

ANALYSIS 

OWCP accepted appellant’s claim for right shoulder tear of the supraspinatus, right 

shoulder partial tear of the infraspinatus and right arm dislocation of the bicep. The issue is 

whether he sustained more than a seven percent permanent impairment of the upper right 

extremity for which he received schedule awards. The Board finds that appellant has not met his 

 15 Id. at 385-419. 

16 Id. at 411. 

17 Id. at 23-28. 

18 Id. at 387. 

19 Id. at 464. 

20 See Federal (FECA) Procedure Manual, Part 2 -- Claims, Schedule Awards and Permanent Disability Claims, 

Chapter 2.808.6 (February 2013). 
5

burden of proof to establish that he has impairment of the right upper extremity greater than the 

seven percent already awarded. 

Dr. Petrisko’s April 5, 2013 report utilized the range of motion method based on 

Table 15-34 to calculate 10 percent permanent impairment of the upper right extremity or 6 

percent whole person impairment.21 The Board notes that there is no statutory basis for the 

payment of a schedule award for whole body impairment under FECA.22 Payment is authorized 

only for the permanent impairment of specified members, organs or functions of the body. The 

Board notes that Dr. Petrisko failed to show how he rated the 10 percent upper right extremity 

impairment and failed to provide valid range of motion measurements as required by Section 

15.7a of the A.M.A., Guides.

23 The Board notes that the A.M.A., Guides require the rating 

physician to obtain three measurements per joint motion. The measurements are then averaged 

and each of the three measurements shown must be within 10 degrees of the calculated average. 

The maximum observed measurement is then used to determine the range of motion 

impairment.24 It does not appear from Dr. Petrisko’s report that he obtained the requisite three 

joint measurements. Consequently, his impairment rating does not conform to the A.M.A., 

Guides and is of diminished probative value.25 

Dr. Petrisko’s report was reviewed by Dr. Slutsky, who noted the above defects. 

Dr. Slutsky found that appellant’s impairment rating should be calculated pursuant the preferred 

diagnosed-based impairment method rather than the alternative range of motion method utilized 

by Dr. Petrisko. He properly noted that Dr. Petrisko’s range of motion measurements were not 

reliable as the physician failed to provide the valid range of motion measurements required by 

Section 15.7a of the A.M.A., Guides.

26

Dr. Slutsky stated that, under Table 15-5 of the A.M.A., Guides, appellant had the 

diagnosis-based condition of full thickness rotator cuff tear with residual dysfunction and, 

therefore, fell under the class 1 default value of five percent impairment. Providing explanations 

for his grade modifiers, he applied Table 15-7 through Table 15-9 to show that appellant had a 

grade modifier 1 for functional history, 0 for physical examination and 4 for clinical studies.27 

Applying the net adjustment formula, Dr. Slutsky properly subtracted 1, the numerical value of 

the Class, from the numerical value of the grade modifier for each component (functional 

history, physical examination and clinical studies) and then added those values, resulting in a net 

adjustment of 2 ((1-1) + (0-1) + (4-1)).28 He noted that application of the net adjustment formula 

 21 Supra note 3. 

22 N.M., 58 ECAB 273 (2007). 

23 Supra note 7. 

24 Supra note 19. 

25 See Mary L. Henninger, 52 ECAB 408 (2001).

26 D.U., Docket No. 13-2086 (issued February 11, 2014). 

27 Supra note 6 through 9. 

28 Supra note 10. 
6

meant that movement was warranted two places to the right of class 1 default value grade C to 

grade E in accordance with Table 15-5. Therefore, Dr. Slutsky properly concluded that the 

diagnosis-based impairment rating for appellant’s right rotator cuff injury full thickness tear with 

residual dysfunction yielded a seven percent impairment of the upper right extremity.29 

The Board finds that appellant has a seven percent permanent impairment of the upper 

right extremity.30 There is no probative evidence showing a greater impairment. 

On appeal, appellant argues that he has continued difficulty performing everyday tasks 

and the medical reports submitted establish greater than seven percent impairment of the right 

upper extremity. As noted above, Dr. Petrisko’s report is insufficient to form the basis of 

appellant’s schedule award claim. The Board further notes that any evidence of record after the 

final decision cannot be considered by the Board.31 The Board’s jurisdiction is limited to 

reviewing the evidence that was before OWCP at the time of its decision.32 It is appellant’s 

burden of proof to establish that he sustained a permanent impairment of a scheduled member as 

a result of an employment injury.33 The medical evidence must include a description of any 

physical impairment in sufficient detail so that the claims examiner and others reviewing the file 

would be able to clearly visualize the impairment with its resulting restrictions and limitations.34 

Appellant did not submit such evidence and thus, OWCP properly awarded him seven percent 

impairment of the right upper extremity.35 

Appellant may request a schedule award or increased schedule award based on evidence 

of a new exposure or medical evidence showing progression of an employment-related condition 

resulting in permanent impairment or increased impairment. 

CONCLUSION 

The Board finds that appellant has no more than seven percent permanent impairment of 

upper right extremity. 

 29 Supra note 5. 

30 Supra note 26. 

31 20 C.F.R. § 510.2(c)(1); Dennis E. Maddy, 47 ECAB 259 (1995); James C. Campbell, 5 ECAB 35, 36 

n.2 (1952). 

32 20 C.F.R § 501.2(c)(1). 

33 Tammy L. Meehan, 53 ECAB 229 (2001). 

34 See A.L., Docket No. 08-1730 (issued March 16, 2009). 

35 V.W., Docket No. 09-2026 (issued February 16, 2010); L.F., Docket No. 10-343 (issued November 29, 2010). 
7

ORDER 

IT IS HEREBY ORDERED THAT the Office of Workers’ Compensation Programs 

decision dated February 25, 2014 is affirmed. 

Issued: September 4, 2014 

Washington, DC 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia Howard Fitzgerald, Judge 

 Employees’ Compensation Appeals Board 

 

 Michael E. Groom, Alternate Judge 

 Employees’ Compensation Appeals Board