United States Department of Labor 

Employees’ Compensation Appeals Board 

________________________________________ 

D.H., Appellant 

and 

DEPARTMENT OF THE NAVY, 

COMMANDER FLEET FORCES COMMAND -- 

SHIPYARDS, Portsmouth, VA, Employer 

___________________________________________

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Docket No. 14-294 

Issued: May 23, 2014 

Appearances: Case Submitted on the Record 

Appellant, pro se

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

COLLEEN DUFFY KIKO, Judge 

MICHAEL E. GROOM, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On November 24, 2013 appellant filed a timely appeal from the August 14, 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.2

 

ISSUE 

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

traumatic injury in the performance of duty on May 8, 2013. 

 1

 5 U.S.C. § 8101 et seq. 

2

 The Board notes that appellant submitted new evidence with her appeal contending that it supported causal 

relationship. The Board cannot consider such evidence, however, for the first time on appeal. The Board’s review 

of the case is limited to the evidence of record which was before OWCP at the time of its final decision. 

20 C.F.R. § 501.2(c); see Steven S. Saleh, 55 ECAB 169 (2003). 
2

FACTUAL HISTORY 

On May 9, 2013 appellant, then a 63-year-old engineering technician, filed a traumatic 

injury claim alleging that on May 8, 2013 she reached in to the bottom of a safe to get some 

compact discs (CDs) when she fell striking her right shoulder. In a May 9, 2013 statement, she 

noted that she had a prior back injury in 1984, which was occupational.3

 Appellant was off work 

from May 9 to 29, 2013. 

By letter dated May 15, 2013, OWCP advised appellant that the claim initially appeared 

to be a minor injury. It administratively approved payment of limited medical expenses. As 

appellant’s medical bills exceeded $1,500.00, it would adjudicate the claim. OWCP informed 

her of the evidence needed to establish her claim. 

In a May 24, 2013 statement, appellant’s supervisor concurred with appellant’s 

description of injury. The injury was reported on May 9, 2013, the day of the incident and 

appellant continued to work for two hours. 

OWCP received reports from Dr. Arthur W. Wardell, a Board-certified orthopedic 

surgeon and treating physician. On May 10, 2013 Dr. Wardell noted that appellant was injured 

at work on May 8, 2013 when she was reaching into a safe at work. Appellant twisted her body 

awkwardly and fell against boxes trying to pick up the CDs. Dr. Wardell advised that, since the 

incident, she had neck pain which radiated to her right shoulder with pain in the upper and lower 

back, which radiated to the right buttock and down to the right posterior thigh. On examination, 

appellant had right paracentral tenderness and spasm and right trapezius tenderness and spasm. 

Shoulder motion was normal. Appellant had right deltoid tenderness, bilateral parathoracic 

tenderness, right parathoracic spasm, bilateral paralumbar tenderness, right piriformis tenderness 

and moderate restriction of low back flexion with pain radiating to the right buttock and right 

posterior thigh. Dr. Wardell noted that cervical spine x-rays showed C6-7 narrowing while the 

right shoulder, dorsal spine, pelvis and lumbosacral spine x-rays were essentially normal. He 

diagnosed cervical spine sprain, dorsolumbar spine sprain, right shoulder sprain and right sciatica 

due to the history of injury. Dr. Wardell checked a box “yes” in response to a form question as 

to whether appellant’s condition was caused or aggravated by an employment activity. He noted 

that she was unable to return to work. 

In reports dated May 29, 2013, Dr. Wardell noted that appellant had eight sessions of 

physical therapy. On examination, appellant’s neck pain was worse together with her lower back 

pain. Dr. Wardell stated that she had 25 percent restricted motion of her neck and tenderness 

over the right trapezius, with moderate restriction of the low back. He repeated advised that 

appellant was unable to return to work. 

On July 1, 2013 Dr. Wardell noted that appellant continued to have some stiffness in her 

neck and lower back, but therapy had helped. Appellant wanted to return to work with 

restrictions. Dr. Wardell determined that she had 10 percent restriction of neck extension and 

flexion, mild right paracervical pain and tenderness, moderate restriction of low back flexion and 

 3

 Appellant also indicated that she had a prior injury to her head. The record reflects that she filed several 

traumatic injury claims. The other claims are not presently before the Board. 
3

negative straight leg raising. He recommended that appellant continue with therapy and resume 

work with restrictions. Dr. Wardell provided a 15-pound lifting restriction and a six-hour 

limitation on bending, stooping, pulling and pushing. 

OWCP also received May 8, 2013 emergency room records noting that appellant was 

treated by a physician’s assistant for cervical muscle spasm. A May 9, 2013 chest x-ray and 

computerized tomography scan of the head were reported as normal. OWCP also received 

reports from attending nurses, physician’s assistants and physical therapists. 

By decision dated August 14, 2013, OWCP denied appellant’s claim. It found that the 

medical evidence did not establish that the claimed medical condition was causally related to the 

accepted incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA4 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 FECA5 and that an injury was sustained in the performance of duty.6 These 

are the essential elements of each compensation claim, regardless of whether the claim is 

predicated upon a traumatic injury or an occupational disease.7

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.8 Second, the employee must submit 

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

employment incident caused a personal injury.9

 

Rationalized medical opinion evidence is generally required to establish causal 

relationship. The opinion of the physician must be based on a complete factual and medical 

background, must be one of reasonable medical certainty and must be supported by medical 

 4

 5 U.S.C. §§ 8101-8193. 

5 Joe D. Cameron, 41 ECAB 153 (1989). 

6 James E. Chadden, Sr., 40 ECAB 312 (1988). 

7 Delores C. Ellyett, 41 ECAB 992 (1990). 

8 Julie B. Hawkins, 38 ECAB 393, 396 (1987); see Federal (FECA) Procedure Manual, Part 2 -- Claims, Fact of 

Injury, Chapter 2.803.2a (June 1995). 

9 See John J. Carlone, 41 ECAB 345, 358 (1989). For a definition of the term “traumatic injury,” see 20 C.F.R. 

§ 10.5(ee). 
4

rationale explaining the nature of the relationship between the diagnosed condition and the 

specific employment factors identified by the claimant.10

ANALYSIS 

Appellant alleged that on May 8, 2013 she reached into a safe to get some CDs and fell 

on a box striking her right shoulder. Her head started hurting along with her back, right shoulder 

and neck. The evidence supports that the May 8, 2013 incident occurred, as alleged. Appellant 

fell against her right shoulder as she reached into a safe. 

The Board finds that the medical evidence is insufficient to establish that the May 8, 2013 

incident caused her injury. The medical evidence contains insufficient rationale on how the 

May 8, 2013 incident caused or contributed to her diagnosed medical condition.11 

Dr. Wardell noted that appellant was injured at work on May 8, 2013 when she fell while 

reaching into a safe at work. Appellant twisted her body awkwardly and fell. After the incident, 

she had pain in the neck which radiated to her right shoulder and pain in the upper and lower 

back, which radiated to the right buttock and to the right posterior thigh. Dr. Wardell diagnosed 

cervical spine sprain, dorsolumbar spine sprain, right shoulder sprain and right sciatica and noted 

they were due to the injury. He checked a box “yes” in response to whether he believed the 

condition was caused or aggravated by an employment activity. Dr. Wardell indicated that 

appellant was unable to return to work. The Board has held that the checking of a box “yes” on a 

form report, without additional explanation or rationale, is not sufficient to establish causal 

relationship.12 Dr. Wardell did not otherwise address why the work incident caused or 

contributed to any of the diagnosed conditions. 

The subsequent reports from Dr. Wardell addressed appellant’s status but did not offer 

any opinion on causal relationship. 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.13 Similarly, reports of diagnostic testing are insufficient because these reports do 

not specifically address whether the May 8, 2013 work incident caused or contributed to a 

diagnosed medical condition. 

OWCP also received reports from nurses, physician’s assistants and physical therapists. 

However, the Board has held that lay individuals such as a physician’s assistant, nurse and 

physical therapist are not competent to render a medical opinion under FECA.14 Only medical 

 10 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 

11 See George Randolph Taylor, 6 ECAB 986, 988 (1954) (where the Board found that a medical opinion not 

fortified by medical rationale is of little probative value). 

12 Linda Thompson, 51 ECAB 694 (2000); Calvin E. King, 51 ECAB 394 (2000). 

13 K.W., 59 ECAB 271 (2007). 

14 E.K., Docket No. 09-1827 (issued April 21, 2010). See 5 U.S.C. § 8101(2) (provides that the term “physician” 

includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors and osteopathic 

practitioners within the scope of their practice as defined by the applicable state law). 
5

evidence from a physician as defined under FECA will be accorded probative value. This 

evidence has no probative medical value.15

Appellant may submit evidence or argument with a written request for reconsideration 

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 in establishing that she 

sustained a traumatic injury in the performance of duty on May 8, 2013. 

ORDER 

IT IS HEREBY ORDERED THAT the August 14, 2013 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: May 23, 2014 

Washington, DC 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Michael E. Groom, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board 

 15 See Jane A. White, 34 ECAB 515, 518 (1983).