United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

H.W., Appellant 

and 

DEPARTMENT OF THE ARMY, RED RIVER 

ARMY DEPOT, Texarkana, TX, Employer 

__________________________________________ 

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Docket No. 16-1060 

Issued: December 7, 2016 

Appearances: Case Submitted on the Record

Michael E. Woods, for the appellant1

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

JURISDICTION 

On April 25, 2016 appellant, through his representative, filed a timely appeal of a 

January 28, 2016 merit decision of the Office of Workers’ Compensation Programs (OWCP). 

Pursuant to the Federal Employees’ Compensation Act2 (FECA) and 20 C.F.R. §§ 501.2(c) and 

501.3, the Board has jurisdiction to consider the merits of this case. 

 1

 In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for 

legal or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. 

§ 501.9(e). No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An 

attorney or representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject 

to fine or imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a 

representative, prior to approval by the Board, may be reported to appropriate authorities for investigation. 

2

 5 U.S.C. § 8101 et seq. 
2

ISSUE 

The issue is whether appellant has met his burden of proof to establish that he sustained a 

left shoulder rotator cuff tear and lumbar radiculopathy causally related to his accepted 

March 14, 1989 employment injury. 

On appeal appellant’s representative contends that appellant has met his burden to 

establish that his left shoulder and lumbar conditions were consequentially related to the 

accepted injury. 

FACTUAL HISTORY 

This case has previously been before the Board.3 The facts and circumstances set forth in 

the prior decision is incorporated herein by reference. The facts relevant to this appeal are as 

follows. 

On March 15, 1989 appellant, then a 41-year-old metal processor/light item handler, filed 

a traumatic injury claim (Form CA-1) alleging that he injured his left shoulder when he tripped 

and fell on March 14, 1989 in the performance of duty. OWCP accepted the claim for left 

shoulder contusion and cervical and lumbar strains and authorized C5-6 an anterior cervical 

discectomy surgery, which occurred on July 12, 1989. Appellant received wage-loss 

compensation benefits on the periodic rolls commencing June 16, 2002. 

On October 31, 1989 appellant filed a traumatic injury claim (Form CA-1) alleging that, 

on October 25, 1989, he reinjured himself when a chair he was sitting in tilted backward as he 

was trying to stand up.4

 OWCP accepted the claim for neck sprain and cervical spondylosis.5 

In progress notes dated May 30, 1990, Dr. Greg Smolarz, a Board-certified orthopedic 

surgeon, noted that based on an x-ray evaluation there were no left shoulder abnormalities. 

An April 4, 1991 magnetic resonance imaging (MRI) scan revealed a left L4-5 

paracentral disc herniation. 

On May 7, 1991 Dr. Contreras diagnosed C6-7 and L4-5 herniated discs based on a 

review of a myelogram. He also noted that appellant had no interest in surgery. 

 3

 By decision dated July 14, 2009, the Board affirmed a February 5, 2008 OWCP decision which denied 

reconsideration of prior OWCP decisions granting appellant a schedule award for 25 percent permanent impairment 

of the left lower extremity. Docket No. 08-1692 (issued July 14, 2009). On August 30 2010 appellant, through his 

representation, filed a request for review of an OWCP decision dated November 24, 2010. By order dated June 2, 

2011, the Board granted appellant’s representative’s request to dismiss the appeal to the Board. Docket No. 11-0917 

(issued June 2, 2011). 

4

 This claim was assigned OWCP File No. xxxxxx951. On May 3, 1990 OWCP combined OWCP File 

Nos. xxxxxx427 and xxxxx951 with the former serving as the master file number. 

5

 The employing establishment terminated appellant’s employment effective July 19, 1990. 
3

In reports dated April 3 and June 8, 1992, and April 19, 1993, Dr. R. Paul Tucker, a 

Board-certified neurologist, found no evidence of a left shoulder rotator cuff tear based on 

review of the April 4, 1991 MRI scan. 

In various reports from November 14, 1996 to November 28, 2000, Dr. Tucker noted that 

a November 8, 1996 MRI scan revealed a right and central large L4-5 disc fragment. 

In a report dated April 24, 1997, Dr. Barry M. Green, a Board-certified orthopedic 

surgeon, diagnosed a large protruding L3-5 disc based on review of a July 8, 1996 MRI scan and 

a normal left shoulder upon review of the MRI scan. 

On July 12, 2004 appellant returned to a limited-duty job working 32 hours per week as a 

motor vehicle operator. 

In attending physician’s reports (Forms CA-20) dated August 1 and 27, 2004, Dr. Tucker 

diagnosed left cervical C6-7 disc disease with stenosis and right lumbar L4-5 disc disease 

“presumably related to” the March 14, 1989 work injury. 

By decision dated September 13, 2004, OWCP issued a loss of wage-earning capacity 

determination, reducing his entitlement to compensation based on his actual wages as a motor 

vehicle operator. 

In an October 11, 2004 report, Dr. Tucker noted that a myelogram performed in 2002 

showed chronic left L2-4 and right L5 neurogenic changes and no evidence of peripheral 

neuropathy. 

In an August 30, 2005 report, Dr. Charles Schultz, a Board-certified neurologist, noted 

that appellant was referred by Dr. Tucker for an evaluation of his chronic pain. He provided a 

history of appellant’s complaints and physical examination findings. Diagnoses included chronic 

C5-6 radiculopathy, cervical and lumbar spondylosis without myelopathy, L2-4 and right L5 

chronic radiculopathy, chronic tension headaches, osteoarthritis, hypertension, and muscle 

cramps with muscle spasms. 

On January 12, 2006 appellant filed a traumatic injury claim (Form CA-1) alleging that 

on January 4, 2006 he injured his neck when a forklift backed into the rear of his motor vehicle. 

OWCP accepted the claim for neck sprain.6

 Appellant stopped work on January 4, 2006 and 

returned to work for four hours per day beginning May 22, 2007. He retired from the employing 

establishment, effective August 12, 2010. 

In an August 10, 2010 report, Dr. William L. Rutledge, a family practitioner, noted that 

he reviewed appellant’s medical records from 2002 to March 2010. He related appellant’s 

history of injury and provided examination findings. Dr. Rutledge opined that appellant’s work 

condition had worsened and he was disabled from performing his date-of-injury job. He noted 

that appellant’s cervical and lumbar disc diseases with stenosis were progressive diseases and 

 6

 This claim was assigned OWCP File No. xxxxxx095. On May 12, 2008 OWCP combined File Nos. xxxxxx427 

and xxxxxx095 with the former severing as the master file number. 
4

that his condition had worsened to include depression from chronic pain, muscular atrophy, and 

weakness. 

On April 11, 2014 appellant underwent MRI scans of the left shoulder and cervical and 

lumbar areas of the spine as well as x-ray interpretation of the lumbar spine. The lumbar MRI 

scan and x-ray scan showed no evidence of instability or loss of disc space in the lumbar spine. 

The left shoulder MRI scan evinced impingement and a partial thickness rotator cuff tear. 

On May 19, 2014 appellant underwent a cervical electromyography/nerve conduction 

velocity (EMG/NCV) study performed by Dr. Patrick Donovan, a Board-certified physiatrist. 

Based on test results, Dr. Donovan diagnosed acute and chronic C5-6 cervical radiculopathy and 

mild left carpal tunnel syndrome. 

A June 3, 2014 lumbar EMG/NCV study was performed by Dr. Donovan. Test results 

were positive for acute and chronic bilateral L5 lumbosacral radiculopathy. 

In a June 3, 2014 report, Dr. Donovan noted that appellant was involved in a March 14, 

1989 lifting injury at work. He further noted that since the injury appellant had developed 

progressive neck and lower back pain and increased bilateral upper and lower extremity 

paresthesias. Physical examination and diagnostic test findings were recorded. 

In a letter dated August 11, 2014, appellant requested that OWCP expand his accepted 

conditions from contusion of the left shoulder and arm, neck, and back sprain, to include left 

shoulder rotator cuff tear and cervical and lumbar radiculopathy. 

In an August 6, 2014 report, Dr. John A. Sazy, an orthopedic surgeon, noted the accepted 

conditions were cervical and lumbar strains, as well as left arm and shoulder contusions. 

Appellant reported severe radiating pain and radiating parenthesis into the left shoulder and arm 

and bilateral thigh posterior parenthesis. He opined that the March 14, 1989 work injury caused 

more severe injuries than the strains and contusion, which had been accepted. According to 

Dr. Sazy, the correct diagnoses due to the March 14, 1989 work injury were cervical disc 

disruption with radiculopathy, lumbar intervertebral disc disease with radiculopathy, and left 

shoulder partial rotator cuff tear with impingement syndrome. 

By correspondence dated August 12, 2014, OWCP informed appellant of the evidence 

necessary to expand acceptance of his claim to include the conditions of left shoulder rotator cuff 

tear, lumbar, and cervical radiculopathy. Appellant was afforded 30 days to provide the 

necessary evidence. 

In an October 15, 2014 report, Dr. Sazy reviewed an October 14, 1993 statement of 

accepted facts (SOAF), a January 7, 2005 addendum, and various diagnostic tests. He noted 

appellant’s medical history and examination findings. Dr. Sazy diagnosed cervical and lumbar 

stenosis with radiculopathy and left shoulder impingement with partial rotator cuff tear, which he 

noted were confirmed by MRI scan and EMG tests. He attributed the diagnosed conditions to 

the March 14, 1989 work injury. In support of this conclusion, Dr. Sazy explained that the 

exertional forces from the 1989 fall accelerated degenerative anatomical changes. Thus, he 

reasoned that appellant’s degenerative changes were not solely the result of aging and 

degenerative processes. Dr. Sazy opined that the conditions accepted by OWCP should be 
5

expanded to include cervical and lumbar decreased intervertebral disc with radiculopathy and 

myelopathy and left shoulder impingement with partial rotator cuff tear. 

On December 1, 2014 OWCP received treatment notes covering the period July 19, 2010 

to October 13, 2014 from Dr. Roshnan Sharma, a Board-certified physiatrist, concerning 

treatment for neck and back pain and EMG studies dated November 30 and December 2, 2010. 

Diagnoses included chronic neck pain, failed neck surgery syndrome, restricted neck range of 

motion, and chronic low back pain. 

On January 5, 2015 OWCP referred the case for review by an OWCP medical adviser 

including an updated SOAF. 

In a January 6, 2015 report, an OWCP medical adviser advised that appellant’s lumbar 

and left shoulder conditions were unrelated to the March 14, 1989 work incident. In support of 

this conclusion, he noted that the April 11, 2014 left shoulder MRI scan findings were unrelated 

to a left-sided contusion sustained 25 years ago. The medical adviser also opined that the lumbar 

abnormalities found on the April 11, 2014 MRI scan were unrelated to the lumbar strain, which 

he noted would have resolved within six to eight weeks. He noted that Dr. Sazy’s reports 

contained no examination findings or history which would be consistent with spinal stenosis. 

Based on a review of the cervical MRI scan, the medical adviser recommended acceptance of a 

consequential displacement of C5-6 and C6-7 intervertebral discs with myelopathy. 

By decision dated January 27, 2015, OWCP accepted displacement of C5-6 and C6-7 

intervertebral discs with myelopathy as causally related to the accepted March 15, 1989 injury. 

On March 2, 2002 appellant was seen by Dr. Jeff Fritz, a Board-certified anesthesiologist, 

for an impairment rating. Dr. Fritz provided a medical history, injury history, and physical 

examination findings. He noted that the accepted conditions were left shoulder/arm contusion, 

cervical disc disease with myelopathy, and neck and lumbar sprains. Dr. Fritz provided an 

impairment rating for the accepted cervical conditions. 

By decision dated March 19, 2015, OWCP denied appellant’s request to expand his claim 

to include left shoulder rotator cuff tear and lumbar radiculopathy. It found Dr. Sazy’s opinion 

insufficiently rationalized, based on lack of explanation regarding the large time gap from the 

March 14, 1989 work injury to the date appellant was diagnosed with left rotator cuff tear and 

lumbar radiculopathy. 

By letter dated March 26, 2015, appellant’s representative requested a telephonic hearing 

before an OWCP hearing representative, which was held on November 17, 2015. 

By decision dated January 28, 2016, an OWCP hearing representative affirmed OWCP’s 

March 19, 2015 decision. The hearing representative found that the medical evidence of record 

was insufficient to support appellant’s contention that he sustained left shoulder rotator cuff tear 

and lumbar radiculopathy due to or as a consequence of the accepted March 14, 1989 

employment injury. 
6

LEGAL PRECEDENT 

An employee seeking benefits under FECA has the burden of proof to establish the 

essential elements of his or her claim including that any disability and/or specific condition for 

which compensation is claimed are causally related to the employment injury.7 

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.8 The medical evidence required to establish causal 

relationship, generally, is rationalized medical opinion evidence. Rationalized medical opinion 

evidence is medical evidence which includes a physician’s rationalized 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 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.9

ANALYSIS 

OWCP accepted that appellant sustained left shoulder contusion and cervical and lumbar 

strains, and authorized a C5-6 anterior cervical discectomy surgery due to the March 14, 1989 

work injury. On January 27, 2015 it expanded acceptance of his claim to include displacement 

of C5-6 and C6-7 intervertebral discs with myelopathy. By decision dated March 19, 2015, 

OWCP denied appellant’s request to accept left shoulder rotator cuff tear and lumbar 

radiculopathy as causally related to the accepted injury. 

The Board finds that appellant has not met his burden of proof to establish that the 

conditions of left shoulder rotator cuff tear and lumbar radiculopathy are causally related to the 

accepted March 14, 1989 employment injury. 

Dr. Sazy began treating appellant in 2014. He diagnosed left shoulder impingement with 

partial rotator cuff tear, as well as lumbar stenosis with radiculopathy. Dr. Sazy contended in his 

August 6 and October 15, 2014 reports that the March 14, 1989 work injury caused more severe 

injuries than what was accepted. In the October 15, 2014 report, he explained that the exertional 

forces from the fall accelerated the degeneration and anatomical changes in appellant’s left 

shoulder as well as his cervical and lumbar spine. Although Dr. Sazy opined that appellant’s left 

shoulder impingement with partial rotator cuff tear and lumbar stenosis with radiculopathy were 

caused, or at the very least aggravated, by the March 14, 1989 work injury, he hid not provide 

sufficient medical rationale supporting this conclusion. The Board has found that medical 

opinions unsupported by rationale are of little probative value.10 Dr. Sazy failed to explain why 

 7 K.G., Docket No. 15-1139 (issued September 28, 2016). 

8 G.M., Docket No. 15-1645 (issued December 7, 2015). 

9 Victor J. Woodhams, 41 ECAB 345 (1989). 

10 M.P., Docket No. 14-1289 (issued September 26, 2014); F.T., Docket No. 09-0919 (issued December 7, 2009); 

Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006). 
7

the rotator cuff tear was not seen on appellant’s May 30, 1990 x-ray of the left shoulder and was 

not found by Dr. Tucker and Dr. Smolarz in their reports covering the period 1990 to 1993. He 

provided no rational as to why this condition was first diagnosed following appellant’s April 11, 

2014 MRI scan, which showed left shoulder impingement with partial rotator cuff tear. 

Dr. Sazy’s opinion is insufficiently rationalized based on an accurate medical history and 

therefore his opinion is insufficient to support that the findings on the 2014 MRI scan of 

appellant’s left shoulder arose from the accepted March 14, 2009 employment injury.11 

Similarly, Dr. Sazy did not explain the lack of a diagnosed lumbar disc condition from 

the 1989 injury until 1991. An April 4, 1991 MRI scan showed a left L4-5 paracentral disc 

herniation. Dr. Sazy’s report is incomplete as it is not based on a review of the complete medical 

record and does not establish a causal relationship between appellant’s current lumbar and left 

shoulder conditions and the accepted work injury.12

OWCP’s medical adviser advised that the left shoulder and lumbar conditions were 

unrelated to the March 14, 1989 work incident as the left shoulder contusion occurred over 25 

years ago and the accepted lumbar strain would have resolved within six to eight weeks. 

Moreover, he noted that Dr. Sazy’s reports provided no examination findings or history 

consistent with spinal stenosis in his reports. The medical evidence of record showed no left 

shoulder abnormality until the April 11, 2014 MRI scan and no lumbar disc condition until a 

November 8, 1996 MRI scan. The Board finds that the opinions expressed by the medical 

adviser were based on a proper medical history and were well rationalized. As such the report of 

the district medical adviser is of probative value.13 

The remaining medical evidence of record is insufficient to satisfy appellant’s burden of 

proof. The reports from Drs. Contreras, Donovan, Fritz, Rutledge, Schultz, Sharma, and Tucker 

are of diminished probative medical value as none of these reports contained an opinion on the 

causal relationship between the lumbar and left shoulder conditions and the accepted March 14, 

1989 work injury. Reports lacking such an opinion are of diminished probative value.14 As none 

of the reports from these physicians provided an opinion as to how these conditions were caused 

by the accepted March 14, 1989 work injury, they are of diminished probative value and are 

insufficient to satisfy his burden of proof. 

Appellant has not met his burden of proof because the medical opinion evidence in this 

case is insufficient to establish the critical element of causal relationship between appellant’s left 

shoulder impingement with partial rotator cuff tear, lumbar stenosis with radiculopathy, and the 

accepted work injury. 

 11 See V.M., Docket No. 15-0601 (issued May 19, 2015). 

12 L.G., Docket No. 09-1692 (issued August 11, 2010); James R. Taylor, 56 ECAB 537 (2005) (medical opinions 

based on an incomplete or inaccurate history are of diminished probative value). 

13 Supra note 9. 

14 See Mary E. Marshall, 56 ECAB 420 (2005) (medical reports that do not contain rationale on causal 

relationship have little probative value). 
8

On appeal appellant’s representative contends that medical evidence submitted 

establishes appellant’s consequential injury claim. When the primary injury is shown to have 

arisen out of and in the course of employment, every natural consequence that flows from the 

injury likewise arises out of the employment, unless it is the result of an independent intervening 

cause.15 An employee who asserts that a nonemployment-related injury was a consequence of a 

previous employment-related injury has the burden of proof to establish such relationship.16 The 

record does not contain rationalized or bridging medical opinion explaining how the diagnosed 

left shoulder impingement with partial rotator cuff tear and lumbar stenosis with radiculopathy 

were consequential injuries of the accepted work injury. There is no evidence of record that the 

accepted employment conditions led to left shoulder impingement with partial rotator cuff tear or 

lumbar stenosis with radiculopathy. As such appellant has not met his burden of proof to 

establish a consequential injury.17

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 has not met his burden of proof to establish that he 

sustained a left shoulder rotator cuff tear and lumbar radiculopathy, causally related to his 

accepted March 14, 1989 employment injury. 

 15 K.R., Docket No. 11-0391 (issued December 21, 2011). 

16 See G.W., Docket No. 11-1985 (issued May 18, 2012). 

17 Supra note 15. 
9

ORDER 

IT IS HEREBY ORDERED THAT the decision of the Office of Workers’ 

Compensation Programs dated January 28, 2016 is affirmed. 

Issued: December 7, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board