United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

K.C., Appellant 

and 

DEPARTMENT OF THE INTERIOR, GREAT 

SMOKEY MOUNTAINS NATIONAL PARK, 

Gatlinburg, TN, Employer 

__________________________________________ 

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Docket No. 15-0552 

Issued: November 10, 2015 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

COLLEEN DUFFY KIKO, Judge 

ALEC J. KOROMILAS, Alternate Judge 

JURISDICTION 

On January 11, 2015 appellant filed a timely appeal of an August 1, 2014 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 to consider the merits of the case.2

ISSUE 

The issue is whether appellant sustained a consequential right hip condition causally 

related to his October 22, 2003 employment injury. 

 1

 5 U.S.C. § 8101 et seq.

2

 Appellant filed a timely request for oral argument, pursuant to 20 C.F.R. § 501.5(b). After exercising its 

discretion pursuant to 20 C.F.R. § 501.5(a) the Board by an October 8, 2015 order, denied his request because it 

could adequately address his contentions based on a review of the case record. Order Denying Request for Oral 

Argument, Docket No. 15-0552 (issued October 8, 2015). 
2

FACTUAL HISTORY 

On October 22, 2003 appellant, then a 47-year-old forestry technician, filed a traumatic 

injury claim (Form CA-1) alleging that on that date he injured his right foot when a several 

hundred pound gate fell on his right foot. He stated that the gate hinge was broken, but there was 

no warning sign. OWCP accepted appellant’s claim for fracture of one or more phalanges of the 

foot. 

Appellant filed a claim for a recurrence of disability (Form CA-7). He claimed that the 

recurrence occurred on April 7, 2008 because on July 6, 2010 he had developed arthritis, that his 

right toe continued to hurt, and that his right toe limited his ability to walk at a normal pace. On 

July 14, 2010 OWCP accepted appellant’s claim for resolved fracture of the right great toe and 

traumatic arthritis of the right great toe. 

On January 31, 2012 appellant requested orthotics for his right foot. He noted difficulty 

receiving this medical treatment on March 13, 2012. On March 30, 2012 appellant requested 

treatment from the University of Pennsylvania. By decision dated April 6, 2012, OWCP denied 

this option and requested that he seek treatment in his local area of Tennessee. 

In a letter dated May 1, 2012, appellant alleged that he had bursitis in his hip and lower 

back pain as the result of improper foot placement due to his right great toe injury. He sought 

approval for right toe surgery. OWCP authorized right great toe surgery on August 16, 2012. 

Dr. Paul Wakefield, a Board-certified family practitioner, examined appellant on May 28, 

2012 due to bursitis of the right hip, osteoarthritis, as well as, allergic rhinitis, hyperlipidemia, 

irritable bowel syndrome, primary insomnia, and thoracic facet syndrome. He diagnosed bursitis 

of the right hip and osteoarthritis. 

In a statement dated August 23, 2012, appellant alleged that he was unable to perform his 

regular job duties due to his accepted condition. He further alleged that his right toe condition 

affected his hip bursitis. 

OWCP updated appellant’s accepted condition in a letter dated October 5, 2012 to 

include hallux rigidus on the right. On October 24, 2012 appellant underwent a first 

metatarsophalangeal joint implant arthroplasty of the right foot. 

Following his October 24, 2012 surgery, appellant submitted several notes from Justin R. 

Shepherd, a physical therapist, opining that delay in surgery for appellant’s right toe resulted in 

his development of bursitis in the right hip and in left foot pain. 

Appellant returned to limited-duty work on December 24, 2012. He returned to full-time 

work on April 18, 2013. Appellant requested a schedule award on April 29, 2013. By decision 

dated July 17, 2013, OWCP granted him a schedule award for eight percent impairment of the 

right leg. 

On February 18, 2014 appellant alleged that his right hip bursitis was painful. He 

indicated that he would like to claim this condition as related to his employment. Appellant 

submitted notes from Mr. Shepherd, the physical therapist, dated October 24, 2012 through 
3

February 14, 2013. Dr. Wakefield completed a note on April 7, 2014 and opined that appellant’s 

recurring bursitis in his right hip was a direct result of the change in his gait to accommodate his 

foot injury. 

OWCP requested additional factual and medical evidence in support of appellant’s claim 

for a consequential condition of right hip bursitis on May 8, 2014. It allowed him 30 days for a 

response. 

Appellant responded on June 8, 2014. He described his employment injury when a 

several hundred pound gate fell directly on his right big toe joint and broke his toe in two places. 

Appellant reported that he developed traumatic arthropathy and required prescription orthotics to 

walk. As his orthotics wore out in November 2011, he became unable to walk appropriately. 

Appellant’s gait was off and he was unable to go up slopes or hills without pain. He noted that 

he went without orthotics for six months. Appellant stated, “During this six month period, I was 

limited to working on level land and not driving government vehicles. During this period of 

time, my gait was extremely off, my left leg had to take the burden of my weight, and my right 

hip was becoming painful.” Appellant received a diagnosis of right hip bursitis in August 2012. 

He utilized stretches to reduce his pain, but continued to experience difficulty sleeping, driving, 

and walking quickly. Appellant reported that when he attempted to go fast this caused hip pain. 

Rob Hawkins, a nurse practitioner, completed a report on August 16, 2012 and diagnosed 

abductor and hip flexor tendinitis of the right hip. 

By decision dated August 1, 2014, OWCP denied appellant’s claim for a consequential 

right hip condition as he had failed to submit the necessary medical opinion evidence to establish 

a causal relationship between his diagnosed condition and his accepted employment injury.3

LEGAL PRECEDENT 

When an injury arises in the course of employment, every natural consequence that flows 

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

intervening cause attributable to claimant’s own intentional conduct.4

 Thus, a subsequent injury, 

be it 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.5

A claimant bears the burden of proof to establish a claim for a consequential injury. As 

part of this burden, he must present rationalized medical opinion evidence, based on a complete 

factual and medical background, showing causal relationship. Causal relationship is a medical 

issue and the medical evidence required to establish causal relationship is rationalized medical 

 3

 Following OWCP’s August 1, 2014 decision, appellant submitted additional new evidence. As OWCP did not 

consider this evidence in reaching a final decision, the Board may not address it for the first time on appeal. 

20 C.F.R. § 501.2(c). 

4 Mary Poller, 55 ECAB 483, 487 (2004); P.H., Docket No. 15-0482 (issued August 4, 2015); 1 Arthur Larson 

and Lex K. Larson, The Law of Workers’ Compensation, 10-1 (2006). 

5 Susanne W. Underwood (Randall L. Underwood), 53 ECAB 139, 141 n.7 (2001). 
4

evidence.6

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

detailed 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 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.7

 Neither the fact that a disease or condition manifests itself during a 

period of employment nor the belief that the disease or condition was caused or aggravated by 

employment factors or incidents is insufficient to establish causal relationship.8

Certain healthcare providers such as physician assistants, nurse practitioners, physical 

therapists, and social workers are not considered physician[s] as defined under FECA.9

 

Consequently, their medical findings and/or opinions will not suffice for purposes of establishing 

entitlement to FECA benefits.10

ANALYSIS 

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

consequential right hip condition as a result of his accepted right toe fracture. 

Appellant has alleged that he developed right hip bursitis as a result of a change in his 

gait due to his accepted right toe fracture, traumatic arthritis of the right great toe, and hallux 

rigidus. He asserted that due to his right toe condition he was unable to walk up and down slopes 

and hills or to travel at the same speed. Appellant stated that walking at his normal rate of speed 

caused his right hip pain. As noted above, his belief that his condition was caused or aggravated 

by his employment injury is insufficient to establish causal relationship.11

Appellant submitted limited medical evidence in support of his claim for a consequential 

injury. Dr. Wakefield completed a note on April 7, 2014 and opined that appellant’s recurring 

bursitis in his right hip was a direct result of the change in his gait to accommodate his foot 

injury. This is the only medical report supporting appellant’s claim for a consequential injury. 

The Board finds that Dr. Wakefield’s report is not sufficient to meet appellant’s burden of proof 

to establish that his right hip bursitis is causally related to his accepted right toe conditions, as 

Dr. Wakefield did not provide any detailed medical reasoning in support of his opinion. While 

Dr. Wakefield opined that appellant’s foot injury resulted in a change in gait, he did not explain 

how this change in gait would have resulted in right hip bursitis. Without further medical 

rationale explaining why and how appellant’s right toe conditions resulted in right hip bursitis, 

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

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

8 Dennis M. Mascarenas, 49 ECAB 215 (1997). 

9

 5 U.S.C. § 8101(2); 20 C.F.R. § 10.5(t). 

10 K.W., 59 ECAB 271, 279 (2007); David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006). 

11 Mascarenas, supra note 8. 
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this report is not sufficiently detailed and well reasoned to meet his burden of proof and establish 

his consequential injury claim. 

Appellant also submitted notes from Mr. Shepherd, the physical therapist, and 

Mr. Hawkins, a nurse practitioner, in support of his consequential injury claim. Neither physical 

therapists nor nurse practitioners are considered physicians for the purposes of FECA.12 Reports 

from these practitioners thus do not constitute medical evidence, and their findings and opinions 

do not suffice for purposes of establishing entitlement to FECA benefits.13

Appellant may submit new evidence or argument as part of a formal 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 submitted sufficient medical opinion evidence to 

establish that he developed right hip bursitis as a consequence of his accepted right toe 

conditions. 

 12 M.G., Docket No. 15-1201 (issued September 15, 2015). 

13 K.W., supra note 10. 
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ORDER 

IT IS HEREBY ORDERED THAT the August 1, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: November 10, 2015 

Washington, DC 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board