United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

J.P., Appellant 

and 

DEPARTMENT OF HOMELAND SECURITY, 

TRANSPORTATION SECURITY 

ADMINISTRATION, Rosemont, IL, Employer 

__________________________________________ 

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Docket No. 15-483 

Issued: May 6, 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 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On December 31, 2014 appellant filed a timely appeal from a December 9, 2014 merit 

decision of the Office of Workers’ Compensation Programs (OWCP) denying her traumatic 

injury claim. 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 her burden of proof to establish that she sustained a 

lower back injury in the performance of duty on September 10, 2014. 

FACTUAL HISTORY 

On September 10, 2014 appellant, then a 52-year-old lead officer, filed a traumatic injury 

claim (Form CA-1) alleging that on that same date she sustained a lower back injury when she 

 1

 5 U.S.C. § 8101 et seq.
2

was getting off a bus and the driver closed the door on her back side. She notified her supervisor 

that same date.2

In a September 11, 2014 hospital discharge note, appellant sought treatment that same 

date with Dr. Bonny Chen, Board-certified in emergency medicine. Education materials were 

provided pertaining to a back sprain. 

In a September 15, 2014 note, Dr. Sarah Siddiqui, a Doctor of Osteopathic Medicine, 

reported that appellant was unable to work until September 22, 2014 and could return to work 

light duty on September 23, 2014. In a referral form that same date, she noted a diagnosis of low 

back pain radiating to both legs and referred appellant to physical therapy. In an October 9, 2014 

note, Dr. Siddiqui excused appellant from work on September 29 and 30, October 8 and 9, 2014 

due to drowsiness from her medication. 

Physical therapy notes dated September 23 to October 24, 2014 from Accelerated 

Rehabilitation Centers were also submitted. 

By letter dated October 31, 2014, OWCP informed appellant that the evidence of record 

was insufficient to support her claim. Appellant was advised of the medical and factual evidence 

needed and was asked to respond within 30 days. 

In medical reports dated September 15 through October 23, 2014, Dr. Siddiqui reported 

that appellant sustained a traumatic work injury in the street on September 10, 2014, complaining 

of pain in the lower back and legs. Upon physical examination, she diagnosed low back pain on 

left side with sciatica. 

In an October 28, 2014 attending physician’s report (Form CA-20), Dr. Siddiqui reported 

that on September 10, 2014 doors closed on appellant at work which caused her the sudden onset 

of severe back pain radiating down her legs. She provided findings of diffuse muscle spasm and 

tenderness in the lumbar region with decreased range of motion tender to palpation and 

movement. Dr. Siddiqui diagnosed low back pain radiating to both legs. She checked the box 

marked yes when asked if she believed the condition was caused or aggravated by the 

employment activity, noting that bus doors closed on appellant. In a duty status report (Form 

CA-17) of that same date, Dr. Siddiqui released appellant to full-duty work. 

Physical therapy notes dated October 21 through 28, 2014 from Accelerated 

Rehabilitation Centers were also submitted. 

By decision dated December 9, 2014, OWCP denied appellant’s claim on the grounds 

that the evidence was insufficient to establish that she sustained an injury. It found that the 

September 10, 2014 incident occurred as alleged. However, the evidence failed to provide a firm 

medical diagnosis which could be reasonably attributed to the accepted employment incident. 

OWCP further noted that the medical evidence submitted contained a diagnosis of “pain” which 

is a symptom and not a diagnosed medical condition. 

 2

 The Board notes that the record reflects that appellant has filed seven other traumatic injury claims filed from 

May 20, 2003 through June 12, 2014. No other information pertaining to these claims is before the Board. 
3

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 filed within the applicable time 

limitation; that an injury was sustained while in the performance of duty as alleged; and that any 

disability or specific condition for which compensation is claimed are 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 on a traumatic injury or an occupational disease.4

In order to determine whether an employee actually sustained a traumatic injury in the 

performance of duty, OWCP begins with an analysis of whether fact of injury has been 

established. Generally, fact of injury consists of two components which must be considered in 

conjunction with one another. The first component to be established is that the employee 

actually experienced the employment incident which is alleged to have occurred.5 The second 

component is whether the employment incident caused a personal injury and generally can be 

established only by medical evidence. 

To establish a causal relationship between the condition, as well as any attendant 

disability claimed and the employment event or incident, the employee must submit rationalized 

medical opinion evidence based on a complete factual and medical background, supporting such 

a causal relationship.6

 The opinion of the physician must be based on 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. 

This medical opinion must include an accurate history of the employee’s employment injury and 

must explain how the condition is related to the injury. The weight of medical evidence is 

determined by its reliability, its probative value, its convincing quality, the care of analysis 

manifested, and the medical rationale expressed in support of the physician’s opinion.7

ANALYSIS 

OWCP accepted that the September 10, 2014 employment incident occurred as alleged. 

The issue, therefore, is whether appellant submitted sufficient medical evidence to establish that 

the employment incident caused a lower back injury. The Board finds that she did not submit 

sufficient medical evidence to support that she sustained an injury causally related to the 

September 10, 2014 employment incident.8

 The medical evidence is deficient on several 

 3 Gary J. Watling, 52 ECAB 278 (2001); Elaine Pendleton, 40 ECAB 1143, 1154 (1989). 

4 Michael E. Smith, 50 ECAB 313 (1999). 

5 Elaine Pendleton, supra note 3. 

6 See 20 C.F.R. § 10.110(a); John M. Tornello, 35 ECAB 234 (1983). 

7 James Mack, 43 ECAB 321 (1991). 

8 See Robert Broome, 55 ECAB 339 (2004).
4

grounds: first, it fails to provide a firm diagnosis; and second, there is no narrative opinion on 

causal relationship between a diagnosed condition and the employment incident. 

In medical reports dated September 15 through October 23, 2014, Dr. Siddiqui reported 

that appellant complained of pain in the lower back and legs after a September 10, 2014 

traumatic work injury while on the street. Upon physical examination, she diagnosed low back 

pain on left side with sciatica. In an October 28, 2014 Form CA-20, Dr. Siddiqui reported that 

on September 10, 2014 bus doors closed on appellant at work which caused the sudden onset of 

severe back pain radiating down the legs. She provided findings of diffuse muscle spasm and 

tenderness in her lumbar region with decreased range of motion tender to palpation and 

movement. Dr. Siddiqui diagnosed low back pain radiating to both legs. She checked the box 

marked yes when asked if she believed the condition was caused or aggravated by the 

employment activity, noting that bus doors closed on appellant. 

Dr. Siddiqui’s diagnosis of low back pain is of no probative value. The Board has 

consistently held that pain and spasm are generally descriptions of symptoms and are not, in 

themselves, considered firm medical diagnoses.9

 Thus, the physician’s clinical findings of 

muscle spasm are also insufficient to establish a firm medical diagnosis as it is generally a 

description of a symptom.10 Dr. Siddiqui’s October 28, 2014 Form CA-20 checked the box 

marked yes to indicate that employment activities caused or aggravated appellant’s injury. The 

Board has held that an opinion on causal relationship that consists only of a physician checking 

yes to a medical form question on whether the claimant’s condition was related to the history 

given is of little probative value.11 Dr. Siddiqui’s report further failed to provide any explanation 

or medical rationale for how appellant’s injury was caused or aggravated by the September 10, 

2014 employment incident. Moreover, while it opined that appellant’s condition was workrelated, she failed to diagnose a medical condition which could be related to the September 10, 

2014 employment incident. Thus, Dr. Siddiqui’s medical reports do not constitute probative 

medical evidence because they fail to provide a clear diagnosis and do not adequately explain the 

cause of appellant’s injury.12 

The physical therapy notes dated September 23 through October 28, 2014 are also 

insufficient to establish appellant’s claim as they were not signed by a physician. Registered 

nurses, physical therapists and physicians assistants, they are not physicians as defined under 

FECA, their opinions are of no probative value.13 

 9 See B.P., Docket No. 12-1345 (issued November 13, 2012) (regarding pain); C.F., Docket No. 08-1102 (issued 

October 10, 2008) (regarding pain); J.S., Docket No. 07-881 (issued August 1, 2007) (regarding spasm). 

10 Id.

11 C.Y., Docket No. 14-2075 (issued March 2, 2015); Deborah L. Beatty, 54 ECAB 334 (2003) (the checking of a 

box yes in a form report, without additional explanation or rationale, is insufficient to establish causal relationship). 

12 Ceferino L. Gonzales, 32 ECAB 1591 (1981). 

13 5 U.S.C. § 8102(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. See also Roy L. Humphrey, 57 ECAB 238 (2005). 
5

The Board has held that the mere fact that a condition manifests itself during a period of 

employment does not raise an inference of causal relation.14 An award of compensation may not 

be based on surmise, conjecture, speculation, or on the employee’s own belief of causal 

relation.15 To establish a firm medical diagnosis and causal relationship, appellant must submit a 

physician’s report in which the physician reviews those factors of employment alleged to have 

caused her condition and, taking these factors into consideration, as well as findings upon 

examination and appellant’s medical history, explain how these employment factors caused or 

aggravated any diagnosed condition, and present medical rationale in support of his opinion.16 

In the instant case, appellant has established that the September 10, 2014 incident 

occurred as alleged. She has failed, however, to establish a firm medical diagnosis causally 

related to the accepted September 10, 2014 employment incident. Thus, appellant has failed to 

meet her burden of proof. 

Appellant may submit additional evidence, together with a written request for 

reconsideration, to OWCP within one year of the Board’s merit decision, pursuant to 5 U.S.C. 

§ 8128(a) and 20 C.F.R. §§ 10.606 and 10.607. 

CONCLUSION 

The Board finds that appellant did not meet her burden of proof to establish that she 

sustained a lower back injury in the performance of duty on September 10, 2014. 

 14 Daniel O. Vasquez, 57 ECAB 559 (2006). 

15 D.D., 57 ECAB 734 (2006). 

16 Supra note 5. 
6

ORDER 

IT IS HEREBY ORDERED THAT the December 9, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: May 6, 2015 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board