United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

C.S., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Larchmont, NY, Employer 

__________________________________________ 

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Docket No. 15-1546 

Issued: November 20, 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 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On July 10, 2015 appellant, through counsel, filed a timely appeal of a March 24, 2015 

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 merit decision in the case. 

ISSUE 

The issue is whether appellant has met her burden of proof to establish an injury causally 

related to a December 3, 2013 employment incident. 

FACTUAL HISTORY 

On December 3, 2013 appellant, then a 43-year-old customer service supervisor, filed a 

traumatic injury claim (Form CA-1) alleging that on that date, while descending steps at work, 

she felt low back pain and her leg gave out causing her to fall and injure her left arm, left 

 

 1 5 U.S.C. § 8101 et seq. 
2

shoulder, and the upper and lower back. She stopped work on December 3, 2013. The 

postmaster noted that on December 3, 2013 at 5:15 a.m. appellant received a call from a clerk 

that appellant fell down the stairs at work and was taken to a hospital. Appellant reported 

descending steps and feeling low back pain which caused her to fall on her left side. 

Appellant was treated in the emergency room on December 3, 2013 for a bone bruise and 

shoulder pain. She submitted a note from Dr. Edward Kirby, a Board-certified orthopedic 

surgeon, dated December 4, 2013, who noted she was excused from work from December 3 

to 14, 2013. In a work capacity form dated December 13, 2013, Dr. Kirby noted that appellant 

could work four hours per day with restrictions. 

By letter dated December 24, 2013, OWCP advised appellant of the type of evidence 

needed to establish her claim, particularly requesting that she submit a physician’s reasoned 

opinion addressing the relationship of her claimed condition and specific employment factors. 

On January 5, 2014 appellant responded to an OWCP questionnaire and noted the cause 

of her back and leg pain was an injury in 2010 in which she injured her right side and lower 

back. She submitted a patient care report from the emergency medical technician who noted that 

appellant was found in the employing establishment at the bottom of the stairs. Appellant 

reported tripping on the stairs and breaking her fall with her left arm. 

In an attending physician’s report (Form CA-16) dated December 3, 2013, Dr. Kirby 

noted that appellant reported falling down. He diagnosed lumbar strain and sprain of the left 

shoulder. Dr. Kirby noted with a checkmark “yes” that appellant’s condition was caused or 

aggravated by an employment activity. He noted that she was totally disabled from December 3, 

2013 to January 2, 2014. In another December 3, 2013 report, Dr. Kirby treated appellant for an 

injury to her left shoulder and low back. Appellant reported falling down four stairs at work and 

injuring her low back and left shoulder. Dr. Kirby noted her history was significant for having 

an ongoing active problem with right-sided low back pain and a herniated disc. He noted 

findings on examination of left shoulder tenderness to palpation over the anterior lateral portion. 

The lower back had tenderness to palpation along the segments. Dr. Kirby diagnosed 

lumbosacral strain, chronic right-sided herniated nucleus pulposus and sprain, and contusion of 

the left shoulder. 

In a December 13, 2013 report, Dr. Kirby noted treating appellant in follow-up for her 

left shoulder and low back work injuries of December 3, 2013. He noted findings and diagnosed 

impingement of the left shoulder and lumbosacral strain and returned her to work with 

restrictions. In a January 2, 2014 report, Dr. Kirby noted that appellant reported the pain in the 

lateral aspect of the left elbow and low back. He noted that examination of the left elbow 

revealed no soft tissue swelling, marked tenderness to palpation over the lateral epicondyle, full 

range of motion, no instability with intact sensation, and reflexes. Examination of the low back 

revealed tenderness and spasm in lower lumbar segments to palpation. Dr. Kirby diagnosed 

lumbosacral strain and lateral epicondylitis, left elbow. He injected the lateral epicondyle with a 

steroid and continued appellant’s work restrictions. 

Appellant also submitted a December 23, 2013 report from Dr. Kenneth Hansraj, a 

Board-certified orthopedic surgeon, who treated her for worsening low back pain that began on 
3

December 3, 2013 after a fall. She reported numbness and weakness in the lower back. 

Dr. Hansraj diagnosed cervical and lumbar spondylosis and diagnostically noted appellant 

complained of low back pain that started on December 3, 2013 as a result of falling. In a note 

dated December 23, 2013, he treated her for cervical and lumbar spondylosis. Dr. Hansraj noted 

that appellant was temporarily disabled and would remain out of work until further notice. 

In a January 24, 2014 decision, OWCP denied the claim finding that the evidence was 

insufficient to establish that she sustained an injury or medical condition which arose during the 

course of employment and within the scope of compensable work factors. 

On January 31, 2014 appellant requested an oral hearing which was held before an 

OWCP hearing representative on August 18, 2014. She was treated by Dr. Gregory 

Chiaramonte, a Board-certified orthopedic surgeon, from January 23 to April 21, 2014. On 

January 23, 2014 Dr. Chiaramonte treated appellant for left shoulder pain after she reported 

falling downstairs at work. He noted acromioclavicular tenderness and equivocal impingement. 

Dr. Chiaramonte diagnosed acromioclavicular injury. On January 29, 2014 he referred appellant 

for physical therapy. In a February 17, 2014 note, Dr. Chiaramonte treated her for left shoulder 

pain and diagnosed bursal tear, surface of the lateral supraspinatus tendon by magnetic resonance 

imaging (MRI) scan. He noted a date of injury of December 3, 2013 and advised that appellant 

could return to work light duty in a week. On April 21, 2014 Dr. Chiaramonte indicated that she 

was still symptomatic after physical therapy. Examination revealed moderate pain with 

restriction on range of motion. Appellant also submitted physical therapy notes. 

In a decision dated November 4, 2014, an OWCP hearing representative affirmed the 

decision dated January 24, 2014. 

On January 12, 2015 appellant requested reconsideration. She submitted a December 4, 

2014 report from Dr. Chiaramonte who noted she fell down stairs at work on December 3, 2013. 

Dr. Chiaramonte noted findings of pain and restricted range of motion. He noted appellant’s 

MRI scan of the right shoulder revealed a rotator cuff tear and probable labral tear. 

Dr. Chiaramonte noted with regard to causal relationship “yes.” 

In a decision dated March 24, 2015, OWCP denied modification of the decision dated 

November 4, 2014. 

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 

of FECA, that an injury was sustained in the performance of duty as alleged, and that any 

disability and/or specific condition for which compensation is claimed are causally related to the 

employment injury. These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated upon a traumatic injury or occupational disease.2

 2 Gary J. Watling, 52 ECAB 357 (2001). 
4

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether fact of injury has been established. 

There are two components involved in establishing fact of injury. First, the employee must 

submit sufficient evidence to establish that she actually experienced the employment incident at 

the time, place, and in the manner alleged. Second, the employee must submit medical evidence 

to establish that the employment incident caused a personal injury.3

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 

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

specific employment factors identified by the claimant.4

ANALYSIS 

It is not disputed that on December 3, 2013 appellant was descending stairs at work, her 

leg gave out, and she fell. It is also not disputed that she was diagnosed with a lumbar strain, left 

shoulder sprain, left lateral epicondylitis, cervical, and lumbar spondylosis, and left rotator cuff 

tear. However, appellant has not submitted sufficient medical evidence to establish that her 

diagnosed conditions were caused or aggravated by this incident at work. 

Appellant submitted reports from Dr. Chiaramonte dated January 23 to April 21, 2014 

who treated her for left shoulder pain after she fell downstairs at work on December 3, 2013. 

Dr. Chiaramonte diagnosed acromioclavicular injury, bursal tear, surface of the lateral 

supraspinatus tendon. He noted appellant was still symptomatic after physical therapy. 

Similarly, a December 4, 2014 report from Dr. Chiaramonte noted that she fell downstairs at 

work on December 3, 2013. He noted that a right shoulder MRI scan revealed a rotator cuff tear 

and probable labral tear. Dr. Chiaramonte noted with regard to causal relationship “yes.” 

Although he supported causal relationship by noting “yes” he did not provide additional medical 

rationale sufficiently explaining the basis of his conclusion opinion regarding the causal 

relationship between appellant’s diagnosed conditions and her fall while descending stairs at 

work. This evidence was insufficient to show that appellant sustained a work-related injury in 

the performance of duty. 

Appellant submitted reports from Dr. Kirby dated December 3, 2013 to January 2, 2014. 

Dr. Kirby noted her history was significant for having an ongoing active problem with rightsided low back pain and a herniated disc. He diagnosed lumbosacral strain, superimposed and 

chronic right-sided herniated nucleus pulposus, sprain and contusion of the left shoulder, and 

lateral epicondylitis, left elbow. However, Dr. Kirby merely repeats the history of injury as 

reported by appellant without providing his own opinion regarding whether her condition was 

work related. To the extent that he is providing his own opinion, Dr. Kirby failed to provide a 

rationalized opinion regarding the causal relationship between appellant’s lumbosacral strain, 

superimposed and chronic right-sided herniated nucleus pulposus, sprain and contusion of the 

 3

 T.H., 59 ECAB 388 (2008). 

4 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 
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left shoulder, and lateral epicondylitis and the factors of employment believed to have caused or 

contributed to such condition.5 Therefore, these reports are insufficient to meet appellant’s 

burden of proof. 

In an attending physician’s report dated December 3, 2013, Dr. Kirby diagnosed lumbar 

strain and sprain of the left shoulder and noted with a checkmark “yes” that appellant’s condition 

was caused or aggravated by an employment activity. He noted that she was totally disabled 

from December 3, 2013 to January 2, 2014. However, the Board has held that an opinion on 

causal relationship which consists only of a physician checking a box marked “yes” regarding 

causal relationship is of little probative value. Without any explanation or rationale for the 

conclusion reached, such a report is insufficient to establish causal relationship.6 Other reports 

from Dr. Kirby are of limited probative value as they did not provide a history of injury or 

specifically address whether appellant’s employment activities had caused or aggravated a 

diagnosed medical condition.7 

Appellant submitted a December 23, 2013 report from Dr. Hansraj who treated her for 

worsening low back pain after a fall on December 3, 2013. Dr. Hansraj diagnosed cervical and 

lumbar spondylosis. In a note dated December 23, 2013, he treated appellant for cervical and 

lumbar spondylosis. Dr. Hansraj noted that she was temporarily disabled and would remain out 

of work until further notice. These reports are insufficient to establish the claim as he did not 

provide a clear history of the work incident in which appellant fell and did not explain how this 

incident caused or aggravated any diagnosed medical condition. 

Appellant also submitted evidence such as emergency room and emergency medical 

technician records that were not signed by a physician. This may not be considered medical 

evidence and is of no probative medical value.8 Likewise, physical therapy records provided by 

appellant are of no probative medical value.9 

An award of compensation may not be based on surmise, conjecture, or speculation. 

Neither the fact that appellant’s condition became apparent during a period of employment nor 

the belief that her condition was caused, precipitated, or aggravated by her employment is 

sufficient to establish causal relationship. Causal relationship must be established by 

 5 Id. 

6 Lucrecia M. Nielson, 41 ECAB 583, 594 (1991). 

7 A.D., 58 ECAB 149 Docket No. 06-1183 (issued November 14, 2006) (medical evidence which does not offer 

any opinion regarding the cause of an employee’s condition is of limited probative value on the issue of causal 

relationship). 

8 See R.M., 59 ECAB 690 (2008); Bradford L. Sullivan, 33 ECAB 1568(1982) (where the Board held that a 

medical report may not be considered as probative medical evidence if there is no indication that the person 

completing the report qualifies as a “physician” as defined in FECA); 5 U.S.C. § 8101(2) (this subsection defines a 

“physician” as surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic 

practitioners within the scope of their practice as defined by State law). 

9 See David P. Sawchuk, 57 ECAB 316 (2006) (lay individuals such as physician assistants, nurses, and physical 

therapists are not competent to render a medical opinion under FECA). 
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rationalized medical opinion evidence.10 Appellant failed to submit such evidence, and OWCP 

therefore properly denied appellant’s claim for compensation. 

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 did not meet her burden of proof to establish an injury 

causally related to a December 3, 2013 employment incident. 

 10 See Dennis M. Mascarenas, 49 ECAB 215 (1997). 
7

ORDER 

IT IS HEREBY ORDERED THAT the March 24, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: November 20, 2015 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board