United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

R.N., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Melville, NY, Employer 

__________________________________________ 

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Docket No. 14-1635 

Issued: January 27, 2015 

Appearances: Case Submitted on the Record

Alan J. Shapiro, Esq., for the appellant 

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 July 15, 2014 appellant, through his attorney, filed a timely appeal from the June 19, 

2014 Office of Workers’ Compensation Programs’ (OWCP) decision, which denied modification 

of a prior merit decision, which found that he did not establish that certain conditions were 

causally related to his accepted employment injuries. 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 his burden of proof in establishing that his 

chondromalacia of the right hip was causally related to his accepted employment injuries. 

FACTUAL HISTORY 

On September 13, 2012 appellant, then a 50-year-old mail handler, filed a traumatic 

injury claim alleging that on that date he was pushing a cage full of magazines when he felt a 

 1

 5 U.S.C. § 8101 et seq.
2

sharp pain in his groin, going up into his hip on the right side while in the performance of duty. 

He stopped work on that date. 

In a September 28, 2012 report, Dr. Gus Katsigiorgis, an orthopedic surgeon and 

osteopath, noted that appellant injured his right hip while at work on September 13, 2012. He 

advised that appellant was performing his work activities and was pushing a cart with injury to 

his hip. Dr. Katsigiorgis indicated that appellant related that “prior to that” his hip was “feeling 

fine.” He diagnosed “right hip sprain, rule out tear.” Dr. Katsigiorgis recommended a magnetic 

resonance imaging (MRI) scan of the right hip. An October 2, 2012 MRI scan of the hips read 

by Dr. Robert Diamond, a Board-certified diagnostic radiologist, revealed a two-millimeter 

inferolateral subcortical acetabular cyst and L5-S1 disc hydration loss with spondylosis. On 

October 25, 2012 Dr. Katsigiorgis noted that appellant was having pain and difficulty about the 

right hip. Appellant related that it was bothering him considerably. Dr. Katsigiorgis examined 

appellant and determined that he had right hip derangement with failed conservative care. He 

requested a right total hip replacement. 

On November 7, 2012 OWCP accepted the claim for sprain of the right hip and thigh. 

Appellant received appropriate compensation for total disability. OWCP explained that it was 

unable to accept hip derangement as his treating physician did not provide a medical narrative 

explaining how this was caused or aggravated by the work incident. 

On December 7, 2012 OWCP received a November 15, 2012 report from 

Dr. Katsigiorgis, who advised that he examined the right hip and determined that appellant had 

restricted range of motion in all planes with tenderness, negative heel strike, and negative log 

roll. Dr. Katsigiorgis diagnosed right hip derangement and requested authorization for a right 

hip replacement. He opined that “the right hip derangement is causally related secondary to the 

work[-]related injury.” In a December 13, 2012 report, Dr. Katsigiorgis reiterated his opinion 

that the right hip derangement and need for surgery were due to work injury, as the work injury 

made the right hip condition symptomatic. 

By decision dated January 4, 2013, OWCP denied appellant’s claim for the condition of 

right hip derangement finding that the medical evidence was insufficient. 

In a January 24, 2013 report, Dr. Katsigiorgis advised that appellant was totally disabled. 

On February 1, 2013 he diagnosed right hip chondromalacia, status post work-related injury and 

opined that he believed that the “chondromalacia of the hip” was “exacerbated secondary to the 

injury at work. Dr. Katsigiorgis was asymptomatic before and this caused symptomatic 

chondromalacia.” He recommended physical therapy and indicated that appellant was disabled 

from work activities. Dr. Katsigiorgis repeated his request for authorization for right total hip 

replacement. 

In a January 28, 2013 report, Dr. Peter G. Sultan, a Board-certified orthopedic surgeon, 

related the history of the work injury and noted appellant’s treatment. He examined appellant 

and provided findings. Dr. Sultan determined that appellant had soft tissue inflammation around 

the hips. He recommended physical therapy. 

On February 20, 2013 OWCP referred appellant to Dr. David Benatar, a Board-certified 

orthopedic surgeon, for a second opinion regarding appellant’s diagnosed conditions and their 

relationship to his employment. In a report dated March 12, 2013, Dr. Benatar described 
3

appellant’s history of injury and treatment and examined him. He diagnosed a right hip 

sprain/strain. Dr. Benatar indicated that impingement and labral pathology should be ruled out. 

He explained that there was no evidence to support how appellant had significant arthritic 

changes that required aggressive intervention. Dr. Benatar explained that the MRI scan did not 

show evidence of a labral tear and impingement was not mentioned. He opined that he did not 

believe that there was an aggravation as there were no significant degenerative changes on the 

diagnostic testing. Dr. Benatar advised that appellant had some continued disability, which was 

partial and not total, which arose from the employment injury. He prescribed restrictions for 

light duty and indicated that appellant had not reached maximum medical improvement. 

On May 13, 2013 Dr. Katsigiorgis performed a right total hip replacement. OWCP did 

not authorize the procedure. 

On November 1, 2013 OWCP referred appellant, along with a statement of accepted 

facts, and the medical record to Dr. David Zitner, a Board-certified orthopedic surgeon, for an 

impartial medical evaluation to resolve the conflict in opinion between Dr. Katsigiorgis and 

Dr. Benatar, the second opinion physician regarding appellant’s diagnosis, whether a causal 

relationship exists between his condition and the accepted work injury, and whether he had 

continuing disability due to the accepted work injury. 

In a November 20, 2013 report, Dr. Zitner noted appellant’s history of injury and 

treatment. He examined appellant and provided findings, which included a dull constant aching 

pain throughout his hip and groin. Dr. Zitner advised that appellant indicated that he had pain at 

night and difficulty sleeping. Appellant also related that his pain increased with sitting, standing, 

walking, extreme range of motion, and with therapy. Regarding the right hip, Dr. Zitner found 

mild-to-moderate reported tenderness about the greater trochanter and posterior hip joint and 

significant tenderness in the groin. He found a well-healed total hip incision with 70 to 80 

percent normal range of motion measured visually limited by pain and some stiffness. Dr. Zitner 

advised that there was no neurologic defect in the lower extremities. He diagnosed right hip 

strain and a possible hernia. Dr. Zitner explained that the injury described was a minor hip strain 

and did not explain the severe persistent symptoms. He opined that he saw “no causal 

relationship between the reported injury and the current treatment [appellant] is receiving and is 

certainly not causally related to any right hip derangement requiring surgery. Dr. Zitner 

explained that appellant had a relatively minor right hip strain as the only orthopedic issue 

involved. He advised that appellant had two hernia surgeries and “[appellant] himself thought he 

could have aggravated his hernia and I think much of his issues are soft tissue related to the groin 

and not necessarily orthopedic in nature.” Dr. Zitner advised that appellant’s current symptoms 

suggested that a hernia could be the case. He explained that appellant’s description and 

mechanism of injury did not explain any of his current symptoms. Dr. Zitner noted that the hip 

MRI scan showed no significant orthopedic pathology that could be explained by the mechanism 

of injury and showed no arthritis that indicated a right hip replacement. He advised that the right 

hip replacement was not indicated and in fact gave him no significant relief after over five 

months and opined that he did not believe that it was necessary or helpful. Dr. Zitner further 

noted that appellant’s current complaints, symptoms, and examination seemed “significantly out 

of proportion to his reported injury and he had no response to orthopedic treatment.” He opined 

that he saw no causal relationship from an orthopedic standpoint and no aggravation of any 

preexisting condition. Dr. Zitner noted that appellant should be evaluated for a hernia and was 
4

capable of sedentary desk work. He noted that appellant was not capable of prolonged standing, 

walking, carrying, or lifting. 

By letter dated December 30, 2013, appellant’s representative requested reconsideration 

from OWCP’s decision dated January 4, 2013. He argued that appellant established that his 

preexisting condition was aggravated and included new medical evidence. In a December 23, 

2013 report, Dr. Katsigiorgis opined: “I do feel that if the history provided is accurate and 

[appellant] has not had any prior injuries to his hip, I do feel that the chronic repetitive activities 

which he states he was doing throughout these 19 years of work, are causally related to his right 

hip derangement.” Appellant continued to submit treatment notes. 

OWCP asked its medical adviser to review Dr. Katsigiorgis’ report. In a May 6, 2014, 

the medical adviser concluded that appellant only sustained a strain of the right hip and the other 

conditions of right hip chondromalacia and degenerative changes were preexisting. He opined 

that the MRI scan findings supported that appellant’s conditions were “preexisting and possibly 

degenerative but not traumatic.” 

In a May 14, 2014 memorandum, OWCP noted that the case was sent to the medical 

adviser to inquire about expanding his accepted condition to include a right hip derangement. It 

noted that a formal decision was issued on January 4, 2013; however, it was indexed incorrectly 

and additional development was undertaken. 

By decision dated June 19, 2014, OWCP denied modification of the January 4, 2013 

decision. It noted the medical development and Dr. Zitner’s referee opinion that appellant had 

only a mild hip strain and no condition that required surgery. 

LEGAL PRECEDENT 

Regarding consequential injuries, the basic rule is that a subsequent injury, whether an 

aggravation of the original injury or a new and distinct injury, is compensable if it is the direct 

and natural result of a compensable primary injury.2

Where an employee claims that a condition not accepted or approved by OWCP was due 

to an employment injury, he or she bears the burden of proof to establish that the condition is 

causally related to the employment injury.3

 To establish a causal relationship between the 

condition claimed, as well as any attendant disability, and the employment event or incident, an 

employee must submit rationalized medical evidence based on a complete medical and factual 

background supporting such a causal relationship.4

 Causal relationship is a medical issue, and 

the medical evidence required to establish a causal relationship is rationalized medical evidence.5

 

Rationalized medical evidence is evidence which includes a physician’s rationalized medical 

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

condition and the implicated employment factors. The opinion of the physician must be based 

 2 S.M., 58 ECAB 166 (2006), citing A. Larson, The Law of Workers’ Compensation § 10.01 (2004). 

3 Jaja K. Asaramo, 55 ECAB 200 (2004). 

4 Jennifer Atkerson, 55 ECAB 317 (2004). 

5 Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000). 
5

on a complete factual and medical background of the claimant, 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 the specific employment factors identified by 

the claimant.6

FECA provides that, if there is a disagreement between a physician making an 

examination for the United States and the physician of the employee, the Secretary must appoint 

a third physician to make an examination.7 Likewise, the implementing regulations state that, if 

a conflict exists between the medical opinion of the employee’s physician and the medical 

opinion of either a second opinion physician or an OWCP medical adviser or consultant, OWCP 

must appoint a third physician to make an examination. This is called a referee examination, and 

OWCP is required to select a physician who is qualified in the appropriate specialty, and who 

has had no prior connection with the case.8 It is well established that, when a case is referred to 

an impartial medical specialist for the purpose of resolving a conflict, the opinion of such 

specialist, if sufficiently well rationalized and based on proper factual and medical background, 

must be given special weight.9 

ANALYSIS 

OWCP accepted the claim for sprain of the right hip and thigh. It denied appellant’s 

claim for chondromalacia of the right hip and did not authorize the May 13, 2013 right total hip 

replacement. The Board finds that he has not met his burden of proof to show that any additional 

right hip condition or surgery is causally related to the accepted condition. 

OWCP properly determined that a conflict existed in the medical opinion evidence as to 

whether appellant had any additional conditions and disability causally related to the 

September 13, 2012 injury. Appellant’s treating physician, Dr. Katsigiorgis, opined that 

appellant’s right hip derangement was secondary to his work-related injury and requested 

authorization for right hip replacement. He also indicated that appellant was totally disabled 

from work. OWCP’s second opinion physician, Dr. Benatar, opined that appellant did not have 

any additional condition causally related to the accepted injury.10 

To resolve the conflict in medical opinion, OWCP referred appellant to Dr. Zitner for an 

impartial medical examination and an opinion as to whether appellant had any additional 

conditions causally related to the September 13, 2012 injury. 

In a November 20, 2013 report, Dr. Zitner noted appellant’s history and treatment. He 

related that appellant indicated that his right hip area remained symptomatic. Dr. Zitner noted 

appellant’s surgery and findings, including mild-to-moderate reported tenderness about the 

greater trochanter and posterior right hip joint, and significant tenderness in the groin. He 

 6 Leslie C. Moore, 52 ECAB 132 (2000). 

7

 5 U.S.C. §§ 8101-8193, 8123(a). 

8

 20 C.F.R. § 10.321. 

9 Gloria J. Godfrey, 52 ECAB 486, 489 (2001). 

10 While he advised that appellant had some disability, Dr. Benatar prescribed restrictions for light duty. 
6

explained that the work injury was a minor hip strain and there was no explanation to support the 

severe persistent symptoms. Dr. Zitner opined that he saw “no causal relationship between the 

reported injury and the current treatment he is receiving and is certainly not causally related to 

any right hip derangement requiring surgery.” He explained that appellant had a relatively minor 

right hip strain as the only orthopedic issue involved. Dr. Zitner noted that appellant related that 

he had two hernia surgeries and “[appellant] himself thought he could have aggravated his hernia 

and I think much of his issues are soft tissue related to the groin and not necessarily orthopedic in 

nature.” He advised that appellant’s current symptoms suggested that a hernia could be the case. 

Dr. Zitner advised that appellant’s description and mechanism of injury did not explain any of 

his current symptoms. He referenced the MRI scan of the right hip and advised that there was no 

significant orthopedic pathology that could be explained by the mechanism of injury and 

furthermore, there was no arthritis that indicated a right hip replacement. Dr. Zitner also 

explained that the right hip replacement gave appellant no significant relief after more than five 

months and opined that he did not believe it was necessary or helpful. He further noted that 

appellant’s current complaints, symptoms, and examination seemed “significantly out of 

proportion to his reported injury and he had no response to orthopedic treatment.” Dr. Zitner 

diagnosed right hip strain and possible hernia. He explained that there was no causal relationship 

from the orthopedic standpoint and no aggravation of any preexisting condition. Dr. Zitner noted 

that appellant was disabled, but needed to be evaluated for a hernia. However, appellant was 

capable of sedentary desk work and noted restrictions. 

The Board finds that OWCP properly relied on Dr. Zitner’s November 20, 2013 report in 

determining that appellant did not have any additional conditions or disability causally related to 

the accepted employment injury. Dr. Zitner’s opinion is sufficiently well rationalized and based 

upon a proper factual background. He examined appellant thoroughly, reviewed the medical 

records, and reported accurate medical and employment histories. Thus, Dr. Zitner’s opinion is 

entitled to special weight.11 

Following Dr. Zitner’s report, OWCP received additional reports from Dr. Katsigiorgis, 

to include his December 23, 2013 report. However, Dr. Katsigiorgis merely reiterated 

previously stated findings and conclusions regarding appellant’s condition. As he had been on 

one side of the conflict in the medical opinion that the impartial specialist resolved, the treating 

physician’s reports were insufficient to overcome the special weight accorded the impartial 

specialist or to create a new medical conflict.12 There are no other current medical reports 

establishing that appellant’s additional right hip conditions, or need for surgery, are causally 

related to his September 13, 2013 work injury.13

 11 See Bryan O. Crane, 56 ECAB 713 (2005). 

12 Alice J. Tysinger, 51 ECAB 638 (2000); Barbara J. Warren, 51 ECAB 413 (2000). 

13 The record also includes a May 6, 2014 report from OWCP’s medical adviser. The Board notes that OWCP 

procedures provide that cases returned from a referee medical examiner should not routinely be sent to an OWCP 

medical adviser for review unless a schedule award is at issue. Federal (FECA) Procedure Manual, Part 2 -- Claims, 

Developing and Evaluating Medical Evidence, Chapter 2.810.11(f) (September 2010). However, the record 

indicates that OWCP referred the matter to the medical adviser to review the December 23, 2013 report of 

Dr. Katsigiorgis and not to critique the impartial specialist’s report. See Richard R. LeMay, 56 ECAB 341 (2005) 

(the resolution of the conflict is the responsibility of the impartial medical specialist). Any error is harmless as 

OWCP’s June 19, 2014 decision did not purport to rely on the medical adviser’s report in reaching its decision. 
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The Board finds that appellant has not met his burden of proof to establish that he had 

any additional conditions or disability causally related to his accepted work injury. Therefore, 

OWCP properly denied his request to expand his claim. 

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 his burden of proof to establish that his 

chondromalacia of the right hip was causally related to his accepted injuries. 

ORDER 

IT IS HEREBY ORDERED THAT the June 19, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: January 27, 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