United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

D.A., Appellant 

and 

DEPARTMENT OF THE ARMY, REDSTONE 

ARSENAL, AL, Employer 

__________________________________________ 

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Docket No. 15-19 

Issued: February 26, 2015 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

COLLEEN DUFFY KIKO, Judge 

PATRICIA HOWARD FITZGERALD, Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On October 2, 2014 appellant filed a timely appeal from an August 26, 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 over the merits of this case. 

ISSUE 

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

performance of duty. 

FACTUAL HISTORY 

On March 20, 2013 appellant, then a 52-year-old budget analysis, filed a traumatic injury 

claim alleging that on March 7, 2013 she reached for a file above her head she felt pain in her 

neck and tingling in her shoulder that radiated down her arm. 

 1

 5 U.S.C. § 8101 et seq. 
2

In a March 13, 2013 report, Dr. Curt Freudenberger, a Board-certified orthopedic 

surgeon, advised that appellant was post anterior cervical discectomy and fusion (ACDF), 

performed on July 17, 2012, and that she may have reinjured her neck a week or so earlier. He 

noted that she was experiencing pain that radiated down her right arm with tingling in her ring 

and small finger. Dr. Freudenberger advised that x-rays showed a C4-6 ACDF with hardware 

intact, increased bridging fusion, and bone-on-bone involvement at C6-7 with principal right 

moderate neural foraminal stenosis. He recommended an epidural steroid injection. In a 

March 13, 2013 disability status report, Dr. Freudenberger advised that appellant was unable to 

return to work until March 28, 2013 and that upon her return she could only perform sedentary 

work. He responded “yes” as to whether her condition was work related. 

Dr. Michael Cosgrove, Board-certified in anesthesiology and pain medicine, in a 

March 15, 2013 report, advised that appellant was scheduled to undergo an epidural block when 

OWCP’s authorization was received. He diagnosed neck/cervical pain and cervical spondylosis. 

On examination, Dr. Freudenberger noted in his March 27, 2013 report that bilateral 

upper extremities were distally intact and that appellant had a positive Spurling’s test with C6 

versus C7 nerve root distribution. 

A March 8, 2013 disability status report from a nurse practitioner at the health unit 

advised that appellant had neck pain running down her right leg and arm. The nurse practitioner 

advised that appellant had a history of degenerative disc disease and that she was unable to work 

until she could be seen by a specialist. A March 11, 2013 treatment record from a nurse 

indicated that Dr. Freudenberger performed a cervical fusion in July 2012 and that appellant had 

a reinjury to the neck in October 2012 and again on March 7, 2013. Also submitted was an 

October 10, 2012 health unit record stating that appellant strained her right shoulder and neck 

while filing on October 9, 2012. 

OWCP informed appellant that it had initially paid a limited amount of medical expenses 

without considering the merits of the claim, as it appeared that the injury was minor with 

minimal or no lost time from work. However, it would now consider the merits of her claim as 

she had requested additional medical treatment. OWCP advised appellant of the type of 

evidence needed to establish her claim. 

Appellant provided a March 27, 2013 disability status report from Dr. Freudenberger who 

advised that appellant’s return to work could not be determined until the results following 

cervical injection were evaluated. Dr. Freudenberger diagnosed neck pain and cervical 

spondylosis and stated “yes” as to whether her condition was work related. 

In a May 10, 2013 statement, appellant advised that on March 7, 2013 she was reaching 

for a thick file above her head when she felt sharp neck pain and lost feeling in her hand. 

By decision dated May 29, 2013, OWCP denied appellant’s claim because the medical 

evidence was insufficient to establish that the diagnosed condition was causally related to the 

work incident. 

In a June 3, 2013 report, a physician assistant advised that appellant underwent a C4 to 

C6 ACDF on July 7, 2012 and was now experiencing pain in the left C7-8 distribution. He 

stated that recently his office had tried to get a cervical epidural steroid injection approved 

“through workman’s comp[ensation]” but this was not found to be warranted. The physician 
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assistant noted findings and diagnosed left ulnar neuropathy and cervicalgia. In an attached 

June 3, 2013 note, Dr. Freudenberger stated that he agreed with the report of his physician 

assistant. He indicated that appellant was doing quite well with regard to her neck although there 

were some concerns about her left arm symptoms. 

On May 22, 2014 appellant requested reconsideration. She stated that she was led to 

believe that Dr. Freudenberger had submitted the required documents. Appellant noted 

submitting documents “that prove that the previous surgery was not involved with my on[-]the[-] 

job injury.” She asserted that a magnetic resonance imaging (MRI) scan showed a C7 extrusion 

that happened when she lifted heavy files above her head. Appellant stated that the denial of 

treatment caused her pain and suffering and was a factor in her early retirement. Accompanying 

her request, she submitted a May 28, 2013 cervical spine MRI scan report from Dr. Timothy 

Baker, a Board-certified diagnostic radiologist, who advised that imaging revealed no acute bony 

injury, no significant spondylolisthesis, anterior fusion from C4-6, and well-maintained 

intervertebral disc spaces. There was a mild broad-based extrusion at C6-7 but no nerve root 

compression. Dr. Baker advised that appellant had postsurgical and degenerative changes and no 

definite nerve root compression or spinal stenosis at any level. Appellant also submitted medical 

reports previously of record. 

Be decision dated August 26, 2014, OWCP denied modification of its May 29, 2013 

decision, finding that medical evidence was insufficient to establish that her diagnosed condition 

was causally related to the work incident. 

LEGAL PRECEDENT 

An employee seeking compensation under FECA has the burden of establishing the 

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

evidence,2 including that he or she is an “employee” within the meaning of FECA and that he or 

she filed his or her claim within the applicable time limitation.3

 The employee must also 

establish that she sustained an injury in the performance of duty as alleged and that her disability 

for work, if any, was causally related to the employment injury.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.5

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 

 2

 J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 57 (1968). 

3 R.C., 59 ECAB 427 (2008). 

4 Id.; Elaine Pendleton, 40 ECAB 1143, 1145 (1989). 

5

 T.H., 59 ECAB 388 (2008). 
4

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

specific employment factors identified by the claimant.6

ANALYSIS 

On March 7, 2013 appellant reached for a file above her head while at work. The 

evidence supports that the claimed work incident occurred. Therefore, the Board finds that the 

first component of fact of injury is established. However, the medical evidence is insufficient to 

establish that the work-related incident on March 7, 2013 caused appellant’s diagnosed 

condition. 

In his March 13 and 27, 2013 disability status reports, Dr. Freudenberger stated “yes” in 

regard to whether appellant’s condition was work related. However, in neither report did 

Dr. Freudenberger explain how reaching for a file on March 7, 2013 caused or aggravated a 

diagnosed medical condition. The Board has held that a medical opinion not fortified by medical 

rationale is of little probative value.7 In his March 13, 2013 treatment report, Dr. Freudenberger 

advised that appellant had a cervical discectomy and fusion on July 17, 2012, and that she may 

have reinjured her neck a week or so earlier. However, he did not reference the specifics of the 

March 7, 2013 work incident or otherwise support causal relationship. Likewise, 

Dr. Freudenberger’s March 27, 2013 report noted appellant’s status but did not specifically 

address causal relationship. The Board has held that medical opinions that do not state an 

opinion on causal relationship are of little probative value.8

 In a June 3, 2013 report, 

Dr. Freudenberger indicated that his office had tried to get a cervical epidural steroid injection 

approved “through workman’s comp[ensation]” but he did not otherwise address why appellant’s 

condition was related to the March 7, 2013 work incident. 

Other medical reports of record, such as Dr. Cosgrove’s March 15, 2013 report and 

Dr. Baker’s May 22, 2013 MRI scan report, are insufficient to discharge appellant’s burden of 

proof because they do not address causal relationship between a diagnosed medical condition 

and the March 7, 2013 work incident.9

OWCP also received evidence from nurses or nurse practitioners at the employing 

establishment’s health unit. However, these reports are not considered medical evidence as they 

are not considered physicians under FECA.10

Consequently, appellant has submitted insufficient medical evidence to establish her 

claim. As noted, she has not submitted reasoned medical evidence, based on an accurate factual 

background, explaining how the March 7, 2013 work incident caused or contributed to a 

diagnosed medical condition. The need for medical reasoning or rationale is particularly 

important where the record indicates that appellant had a serious previous condition to the same 

 6 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 

7 Brenda L. DuBuque, 55 ECAB 212 (2004). 

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

9 See id.

10 Sean O’Connell, 56 ECAB 195 (2004). See 5 U.S.C. § 8101(2). 
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area of the body. Because appellant has not provided such medical opinion evidence in this case, 

she has failed to meet her burden of proof. 

On appeal, appellant asserts that the present matter should have been processed under a 

claim for an October 1990 injury to her neck or back. The Board notes, however, that the record 

reflects an intervening incident on March 7, 2013. As such it was properly handled as a new 

traumatic injury.11

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 did not meet her burden of proof to establish that she 

sustained a traumatic injury in the performance of duty on March 7, 2013. 

ORDER 

IT IS HEREBY ORDERED THAT the August 26, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: February 26, 2015 

Washington, DC 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia Howard Fitzgerald, Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board 

 11 See Bryant F. Blackmon, 56 ECAB 752 (2006).