United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

M.A., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Palatine, IL, Employer 

__________________________________________ 

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Docket No. 16-0227 

Issued: April 1, 2016 

Appearances: Case Submitted on the Record

Appellant, pro se 

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 November 13, 2015 appellant filed a timely appeal from an October 23, 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 merits of this case.2

ISSUE 

The issue is whether appellant has established that her right shoulder condition is causally 

related to the accepted July 25, 2015 employment incident. 

 1

 5 U.S.C. § 8101 et seq.

2

 The Board notes that appellant submitted additional evidence following the October 23, 2015 decision. Since 

the Board’s jurisdiction is limited to evidence that was before OWCP at the time it issued its final decision, the 

Board may not consider this evidence for the first time on appeal. See 20 C.F.R. § 501.2(c)(1); Sandra D. Pruitt, 57 

ECAB 126 (2005). 
2

FACTUAL HISTORY 

On July 27, 2015 appellant, then a 32-year-old sales and distribution associate, filed a 

traumatic injury claim (Form CA-1) alleging that on July 25, 2015 she injured her right shoulder 

when she lifted several tubs filled with mail weighing 60 pounds or more. She stopped work on 

July 27, 2015. 

Appellant was initially examined on July 27, 2015 by Dr. Timothy B. Trusowych, an 

osteopath who specializes in occupational medicine. He noted diagnoses of shoulder strain and 

trapezius strain. Dr. Trusowych recommended that appellant return to work on July 28, 2015 

with restrictions of no lifting over 10 pounds and no reaching above the shoulders. He included 

a duty status report (Form CA-17) which restricted appellant to work with no lifting of his arm. 

In July 29 and August 5, 2015 work activity status reports, Dr. Imran H. Kazmi, a Boardcertified internist, diagnosed shoulder and upper arm strain, trapezius strain, and cervical 

radiculopathy. He authorized appellant to return to work with restrictions of no reaching above 

the shoulders and lifting with the right upper extremity. 

Appellant submitted an unsigned Form CA-16 dated July 29, 2015. She indicated that 

she worked as a customer service clerk and that on July 25, 2015 she was lifting tubs filled with 

catalogs weighing more than 60 or 70 pounds. On the back of the claim form, a physician with 

an illegible signature described the injury as a “lifting injury” and diagnosed right trapezius and 

shoulder strain. The physician checked “yes” that appellant’s condition was caused or 

aggravated by the described employment activity. Appellant was authorized to return to work 

with restrictions of no lifting of the right upper extremity and no reaching above the shoulder. 

Appellant underwent an examination by Dr. Greg White, a Board-certified diagnostic 

radiologist, who indicated in a July 29, 2015 report that appellant experienced an acute injury 

and shoulder pain. He observed acromioclavicular (AC) joint osteoarthritis and a full-thickness 

supraspinatus tendon tear that extended into the infraspinatus tendon. Dr. White also reported 

subscapularis tendinosis, biceps tendon tear, ganglion cyst, and subcoracoid bursitis. He further 

noted possible loose body near the torn infraspinatus tendon and a likely degenerative type labral 

tear. 

On July 31, 2015 appellant began physical therapy treatments. She provided appointment 

details and treatment notes dated July 31 to August 5, 2015. 

In an August 4, 2015 statement, appellant reported that on July 25, 2015 she worked three 

skids that contained tubs full of catalogs weighing more than 70 pounds. She related that on the 

car ride home she felt a very sharp pain in her arm so she went to the emergency room. The 

emergency room physician informed her that she pulled a nerve and prescribed medication. 

Appellant stated that she did not work on Sunday and informed her supervisor. On Monday she 

returned to work with a doctor’s note restricting her to work with only her left arm. When the 

Postmaster saw her he advised that she stop work and go to an employing establishment 

physician. When appellant was examined by that physician, she was advised to work without 

using her right arm and to go to physical therapy. She stated that she returned to work and 
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provided the doctor’s note to the Postmaster. He informed appellant that there was no work 

within her limitations and advised her to go home. 

Appellant provided a Request of Absence for continuation of pay for the dates July 28 to 

August 11, 2015. The employing establishment denied the request and indicated that an 

employee must use sick or annual leave for the first three days following injury. 

On August 19, 2015 appellant underwent a surgical consultation with Dr. Kevin Tu, a 

Board-certified orthopedic surgeon who specializes in sports medicine. He related that on 

July 25, 2015 appellant injured her right shoulder at work when she was emptying out skids. 

Dr. Tu noted that this activity required repetitively lifting tubs of mail. He indicated that after 

work appellant began to experience right shoulder pain and difficulty with overhead activities. 

Dr. Tu reported that appellant underwent physical therapy but experienced minimal improvement 

with her symptoms. He reviewed appellant’s history and related that a right shoulder magnetic 

resonance imaging (MRI) scan revealed a large full-thickness rotator cuff tear. Upon 

examination of appellant’s right shoulder, Dr. Tu observed no tenderness over the AC joint or 

cross body adduction. Forward elevation was to 120 degrees; external rotation was to 60 

degrees; and internal rotation was to the iliac crest. Neer impingement and Hawkins 

reinforcement tests were positive. Dr. Tu advised appellant that he would schedule her for 

surgery as soon as it was authorized. 

On September 11, 2015 Dr. Tu requested authorization for right shoulder arthroscopy 

surgery. 

By letter dated September 18, 2015, OWCP advised appellant that her claim was initially 

accepted as a minor injury but was reopened for review of the merits because appellant had not 

returned to work. It requested additional factual and medical evidence to establish that appellant 

sustained a diagnosed condition as a result of the July 25, 2015 employment incident. 

Appellant filed various Form CA-7 claims for disability compensation for the period 

September 12 to October 16, 2015. 

Dr. Tu re-examined appellant on September 23, 2015. He related that appellant still 

experienced difficulty with lifting activities and overhead activity. Upon examination, Dr. Tu 

observed positive Neer impingement and Hawkins reinforcement tests. Range of motion 

examination revealed forward elevation 1 to 5 degrees, external rotation to 60 degrees, and 

internal rotation to the iliac crest. Dr. Tu reported no tenderness over the AC joint or with cross 

body adduction. O’Brien and Speed tests were negative. Dr. Tu diagnosed right shoulder acute 

on chronic rotator cuff tear. He indicated that he was still awaiting approval for right shoulder 

surgery. 

On September 25, 2015 OWCP received appellant’s response to its development letter. 

She stated that on July 25, 2015 her supervisor asked her to drop the tubs by each route. 

Appellant noted that each tub weighed 70 pounds or more and that she completed three skids 

each that contained approximately 45 tubs. She related that after completing three skids she 

informed her supervisor that she could not continue. Appellant noted that the pain in her right 

shoulder was very strong and that she went to the emergency room for treatment. She was put 
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on limited duty, but her Postmaster informed her that they could not accommodate her 

restrictions. Appellant described the medical treatment she received. She noted that she 

underwent an x-ray, MRI scans, and physical therapy treatments, but saw little improvement. 

Appellant was referred to an orthopedic surgeon who recommended surgery. 

In a decision dated October 23, 2015, OWCP denied appellant’s claim. It accepted that 

the July 22, 2015 incident occurred as alleged, but denied her claim finding insufficient medical 

evidence to establish that her right shoulder condition was causally related to the accepted 

incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA3 has the burden of proof to establish the 

essential elements of her claim by the weight of the reliable, probative, and substantial evidence4

including that she sustained an injury in the performance of duty and that any specific condition 

or disability for work for which she claims compensation is causally related to that employment 

injury.5

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.6 

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.7 Second, the employee must submit evidence, 

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

incident caused a personal injury.8 An employee may establish that the employment incident 

occurred as alleged but fail to show that her disability or condition relates to the employment 

incident.9

Whether an employee sustained an injury in the performance of duty requires the 

submission of rationalized medical opinion evidence.10 The opinion of the physician must be 

based on a complete factual and medical background of the employee, 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 

 3 Supra note 1. 

4 J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968). 

5 G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989). 

6 S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005). 

7 Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968). 

8

 David Apgar, 57 ECAB 137 (2005); John J. Carlone, 41 ECAB 354 (1989). 

9 T.H., 59 ECAB 388 (2008); see also Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006). 

10 See J.Z., 58 ECAB 529 (2007); Paul E. Thams, 56 ECAB 503 (2005). 
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the employee.11 The weight of the 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.12

ANALYSIS 

Appellant has alleged that on July 25, 2015 she sustained a right shoulder injury when 

she lifted heavy tubs filled with mail in the performance of duty. OWCP accepted that the 

July 25, 2015 incident occurred as alleged, but it denied her claim as she had not established that 

her right shoulder condition resulted from the accepted incident. The Board affirms this finding. 

Appellant was initially examined by Drs. Trusowych and Kazmi. In reports dated July 27 

to August 5, 2015, they noted diagnoses of shoulder and upper arm strain, trapezius strain, and 

cervical radiculopathy. Drs. Trusowych and Kazmi authorized appellant to return to work with 

restrictions of no reaching above the shoulders and no lifting of the right arm. Although both 

physicians provided a medical diagnosis, none of the physicians described the July 25, 2015 

employment incident or provided an opinion as to the cause of appellant’s diagnosed conditions. 

The Board has held that 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 These 

reports, therefore, are insufficient to establish appellant’s claim. Similarly, the July 29, 2015 

MRI report of Dr. White also failed to establish causal relationship as he did not address the 

cause of appellant’s right shoulder condition. 

On August 19, 2015 appellant underwent a surgical consultation with Dr. Tu. He 

described the July 25, 2015 employment incident and reviewed appellant’s history. Dr. Tu 

related that the July 29, 2015 MRI scan of the right shoulder revealed a large full-thickness 

rotator cuff tear. He conducted an examination and advised appellant that he would schedule her 

for surgery as soon as it was authorized. On September 23, 2015 Dr. Tu re-examined appellant. 

He provided examination findings and diagnosed right shoulder acute on chronic rotator cuff 

tear. Although Dr. Tu accurately described the July 25, 2015 incident and diagnosed right 

shoulder rotator cuff tear based on physical examination, the Board finds that he did not offer 

any explanation on how appellant’s right shoulder condition resulted from the July 25, 2015 

employment incident. The Board has held that a physician must provide a narrative description 

of the identified employment incident and a reasoned opinion on whether the employment 

incident described caused or contributed to appellant’s diagnosed medical condition.14 Dr. Tu 

did not provide any opinion, based on medical rationale, explaining how the July 25, 2015 

employment incident caused or contributed to appellant’s right shoulder condition. His reports, 

therefore, are insufficient to establish appellant’s traumatic injury claim. 

 11 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 465 (2005). 

12 James Mack, 43 ECAB 321 (1991). 

13 C.B., Docket No. 09-2027 (issued May 12, 2010); J.F., Docket No. 09-1061 (issued November 17, 2009); A.D., 

58 ECAB 149 (2006). 

14 John W. Montoya, 54 ECAB 306 (2003). 
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The issue of causal relationship is a medical question that must be established by 

probative medical opinion from a physician.15 Because appellant has not provided such 

probative medical evidence in this case, the Board finds that she did not meet her burden of proof 

to establish her claim. 

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 establish that her right shoulder condition is 

causally related to the July 25, 2015 employment incident. 

ORDER 

IT IS HEREBY ORDERED THAT the October 23, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: April 1, 2016 

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 

 15 W.W., Docket No. 09-1619 (June 2, 2010); David Apgar, 57 ECAB 137 (2005).