United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

D.B., Appellant 

and 

DEPARTMENT OF THE AIR FORCE, OGDEN 

UTAH - OAMA, RANDOLPH AIR FORCE 

BASE, TX, Employer 

__________________________________________ 

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Docket No. 15-1507 

Issued: October 26, 2015 

Appearances: Case Submitted on the Record

Lennin V. Perez., for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On July 6, 2015 appellant, through his representative, filed a timely appeal from a 

May 26, 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 met his burden of proof to establish that he developed a 

right leg or back injury as a result of his federal employment duties. 

 1

 5 U.S.C. § 8101 et seq.

2

 The Board notes that appellant has two other occupational disease claims which are currently on appeal before 

the Board, Claim No. xxxxxx584 Docket No. 15-1501 (issued October 19, 2015) and Claim No. xxxxxx967 

Docket No. 15-1506 (issued October 26, 2015). The findings in this Claim No. xxxxxx820, pertain to his right leg 

and back conditions only. 
2

FACTUAL HISTORY 

On April 21, 2014 appellant, then a 60-year-old sheet metal mechanic, filed an 

occupational disease claim (Form CA-2) alleging that he developed back pain and right leg 

numbness as a result of his federal employment duties. He first became aware of his condition 

on April 1, 2010 and of its relationship to his employment on March 13, 2014. Appellant first 

sought medical treatment on January 10, 2014. Appellant’s supervisor noted on the claim form 

that he had stopped work on September 25, 2013. 

By letter dated May 2, 2014, OWCP informed appellant that the evidence of record was 

insufficient to support his claim. It noted that he failed to identify the cause of his injury and no 

evidence was received. Appellant was advised of the factual and medical evidence needed and 

was afforded 30 days to respond. 

By letter dated May 7, 2014, the employing establishment controverted the claim. An 

official position description for a sheet metal mechanic and notification of personnel action 

(Form SF-50) was submitted. 

By letter dated January 10, 2014, Dr. Jeffery Lee DeGrauw, Board-certified in family 

medicine, reported that appellant was his patient for several years and was permanently disabled 

due to his gradual and progressive decline in functional ability. He noted limitations in both 

physical and cognitive abilities with significant impairment in short-term memory. Dr. DeGrauw 

reported significant arthritic changes involving the hands, neck, lower back, and shoulders which 

prevented appellant from using his lower and upper extremities. He further diagnosed 

Raynaud’s syndrome, hearing impairment, and cognitive impairment which prevented appellant 

from returning back to the workforce. 

In a February 28, 2014 medical report, Dr. DeGrauw reported that appellant had chronic 

shoulder and neck injuries either related to or associated with his employment. He had a 

magnetic resonance imaging (MRI) scan and a surgical consultation as multiple medical opinions 

found him unfit to return to regular activities. Dr. DeGrauw noted factors that could affect or 

aggravate appellant’s condition involved jobs which required working with his hands above his 

shoulders and/or repetitive pushing, lifting, or pulling activities. He further noted that appellant 

had significant issues with bending and twisting of the neck and torso area and was further 

limited by his functional ability in the hands, elbows, and shoulders associated with degenerative 

arthritis from chronic occupational use. Dr. DeGrauw reported a history of sinus surgery in 2001 

and 2003, as well as bilateral shoulder surgery in 2013. He provided findings on physical 

examination and noted right and left lower extremity musculoskeletal strength was normal. 

Dr. DeGrauw reported that even though the muscle groups had normal strength, range of motion, 

and function, the neck, back, and shoulder were severely limited due to pain associated with 

arthritis. He also diagnosed Raynaud’s syndrome stemming back to March 3, 2011, Alzheimer’s 

dementia, and degenerative joint disease in multiple locations including the neck, shoulders, 

elbows, wrists, hands, and upper and lower back. Dr. DeGrauw reported that these limitations 

precluded appellant from ever returning to work. 

In a February 25, 2014 medical report, Dr. Christopher Kleinsmith, a doctor of 

osteopathic medicine, reported that appellant was being evaluated for a formal fitness-of-duty 
3

examination for his job as a sheet metal mechanic due to ongoing neck and shoulder pain, 

hearing loss, and Alzheimer’s dementia. He noted review of MRI scan results for the cervical 

spine and brain from 2002 to 2004. Dr. Kleinsmith diagnosed Alzheimer’s disease, shoulder 

joint pain, rotator cuff tendinitis, and sensorineural hearing loss. 

In a May 10, 2014 e-mail correspondence, appellant’s wife reported that he believed his 

back issues were due to 30 years of work-related lifting and bending required for his job.3 The 

lifting of 150- to 175-pound horizontal stabilizers was most likely the main contributor. 

Appellant and his coworkers were told on numerous occasions that they would be given a hoist 

to lift the stabilizers, but were never provided with one. 

By decision dated July 25, 2014, OWCP denied appellant’s claim finding that the 

evidence did not establish that the occupational exposure occurred as alleged. It also found that 

appellant failed to establish a firm medical diagnosis which could be reasonably attributed to the 

alleged occupational exposure. 

Documentation was provided dated July 16, 2014 indicating that appellant was separated 

from his employment as a sheet metal mechanic due to his physical inability to perform the 

duties of that position. 

On July 28, 2014 appellant, with assistance of his representative, requested an oral 

hearing before an OWCP hearing representative. He submitted numerous x-ray images of the 

cervical and lumbar spine. The images were not accompanied by a medical report interpreting 

the findings and did not identify a physician or date of study. 

In a May 21, 2014 medical report, Dr. DeGrauw reported that appellant was his patient 

for several years and was permanently disabled. He noted that in January 2014 appellant was 

diagnosed with Alzheimer’s-type dementia. Dr. Kleinsmith speculated that his dementia could 

be related to exposure from hazardous work chemicals. He noted that appellant experienced 

numbness, tingling, and pain involving the tips of his fingers and earlobes. In March 2011, 

appellant was diagnosed with Raynaud’s syndrome. Dr. DeGrauw reported that appellant had no 

prior similar symptoms and opined that Raynaud’s syndrome was caused by the use of 

pneumatic tools. He further noted that the continual use of these pneumatic tools could 

eventually lead to amputation of the fingers due to their effect on circulation. Dr. Kleinsmith 

further diagnosed chronic degenerative joint disease in multiple areas of the body including the 

lower back, upper back, neck, shoulders, wrists, and elbows. Chronic problems related to the 

neck and back stemmed back to 2002 with incidences as far back as 1987. Dr. DeGrauw 

explained that appellant’s work as a sheet metal mechanic for the past 30 years involved lifting 

heavy items weighing 150 to 175 pounds, frequent bending and stooping approximated at 

80 degree angles for 70 to 80 percent of the day, and frequent bending over using pneumatic 

bands to apply sheet metal. He noted that the repetitive heavy lifting involved multiple aspects 

of appellant’s body including his lower back, upper back, neck, shoulders, wrists, and elbows. 

 3

 Appellant provided authorization to allow his wife to speak on his behalf pertaining to his workers’ 

compensation claims. 
4

Dr. DeGrauw also diagnosed tendinitis and carpal tunnel syndrome in the hands and 

elbows, stemming back to 2013. He explained that appellant’s job involved gripping and 

handling tools 100 percent of the time. Dr. Kleinsmith further noted issues with chronic 

migraine and tension headaches. He reported that, over the past several years, appellant had 

been seen and treated for the various above mentioned-illnesses by neurology, orthopedics, and 

primary care physicians which were too numerous to be documented. Dr. Kleinsmith concluded 

that appellant was unable to work and was permanently disabled. 

A hearing was held on March 11, 2015 and appellant was represented. At the hearing, 

appellant testified regarding his federal employment and work exposure. He stated that his work 

as a riveter and sheet metal mechanic required him to lift 175-pound stabilizers roughly 60 times 

a day which entailed constant lifting, bending over, twisting, turning, and stretching. Appellant 

noted that it typically required two people to lift the stabilizers in order to remove and replace 

rivets. He performed this task since 2001. Appellant argued that this task, along with constant 

bending, caused his back and right leg injury. He explained that his work required him to bend 

over and look down at whatever he was working on for the entirety of his shift. Appellant stated 

that he worked 10 hours a day and overtime two days a week, averaging about 50 to 60 hours per 

week. He reported that he had not worked in the shop since 2013 due to a work-related bilateral 

shoulder surgery.4

 Appellant had no prior injuries or problems with his back or legs until he was 

required to lift these stabilizers. 

Following the hearing, notification of Personnel Action forms and official position 

descriptions were submitted indicating that appellant began working as a sheet metal mechanic 

on May 13, 1985. 

In an undated narrative statement, appellant provided a detailed description of his 

employment duties and the tools he used. He stated that he worked full time Monday through 

Thursday, 10 hours daily. Appellant stated that he was constantly exposed to harmful chemicals 

and used pneumatic tools which were heavy, loud, and vibrated in his hands. He provided 

details pertaining to his work with inlet rings and stabilizers and further explained that his duties 

entailed going up and down stairs, lifting heavy equipment, bending, stooping, twisting, and 

turning. Appellant stated that his employment duties resulted in his injuries which forced him to 

start cutting back his hours. He provided official position descriptions, pictures of the tools he 

used, and explanations pertaining to the frequency and mechanics of each of his work-related 

tasks. 

By decision dated May 26, 2015, an OWCP hearing representative affirmed the July 25, 

2014 decision finding that appellant failed to establish a firm medical diagnosis which could be 

reasonably attributed to his federal employment duties. 

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 

 4

 The Board notes that the record contains no other information pertaining to appellant’s bilateral shoulder injury 

claim. 
5

States” within the meaning of FECA; that the claim was filed within the applicable time 

limitation; that an injury was sustained while in the performance of duty as alleged and that any 

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

employment injury.5

 These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated on a traumatic injury or occupational disease.6

In order to determine whether an employee actually sustained an injury in the 

performance of duty, OWCP begins with an analysis of whether fact of injury has been 

established. Generally, fact of injury consists of two components which must be considered in 

conjunction with one another. The first component to be established is that the employee 

actually experienced the employment incident which is alleged to have occurred.7 The second 

component is whether the employment incident caused a personal injury and generally can be 

established only by medical evidence. 

To establish that an injury was sustained in the performance of duty in a claim for 

occupational disease, an employee must submit: (1) a factual statement identifying employment 

factors alleged to have caused or contributed to the presence or occurrence of the disease or 

condition; (2) medical evidence establishing the presence or existence of the disease or condition 

for which compensation is claimed; and (3) medical evidence establishing that the diagnosed 

condition is causally related to the employment factors identified by the employee.8 

To establish a causal relationship between the condition, as well as any attendant 

disability claimed and the employment event or incident, the employee must submit rationalized 

medical opinion evidence based on a complete factual and medical background, supporting such 

a causal relationship.9

 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. This medical opinion 

must include an accurate history of the employee’s employment injury and must explain how the 

condition is related to the injury. The weight of 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.10

ANALYSIS 

Appellant has established that he engaged in repetitive activities of lifting, bending, 

twisting, and turning as a sheet metal mechanic. The issue, therefore, is whether he submitted 

 5 Gary J. Watling, 52 ECAB 278 (2001); Elaine Pendleton, 40 ECAB 1143, 1154 (1989). 

6 Michael E. Smith, 50 ECAB 313 (1999). 

7 Elaine Pendleton, 40 ECAB 1143 (1989). 

8 See Roy L. Humphrey, 57 ECAB 238, 241 (2005); Ruby I. Fish, 46 ECAB 276, 279 (1994). 

9 See 20 C.F.R. § 10.110(a); John M. Tornello, 35 ECAB 234 (1983). 

10 James Mack, 43 ECAB 321 (1991). 
6

sufficient medical evidence to establish that the employment exposure caused him a right leg or 

back injury. This is a medical question. The Board finds that appellant did not submit sufficient 

medical evidence to support that he sustained a right leg and back injury causally related to 

factors of his federal employment as a sheet metal mechanic.11 

In support of his claim, appellant submitted medical reports dated January 10, February 

28, and May 21, 2014 from Dr. DeGrauw, his treating physician. The Board notes that he is 

alleging right leg numbness and back pain in this occupational disease Claim No. xxxxxx820. 

Specifically, appellant has alleged that repetitive bench work and lifting of stabilizers caused him 

a right leg and back injury. Thus, Dr. DeGrauw’s opinions pertaining to other conditions not 

claimed as work related in this claim are irrelevant and of no probative value to the issue of 

whether appellant’s right leg and back injury are caused by his occupational employment duties. 

The Board finds that the medical opinions of Dr. DeGrauw are not well rationalized. In 

his February 28 and May 21, 2014 reports, Dr. DeGrauw diagnosed degenerative joint disease of 

the upper and lower back. He failed to provide a detailed medical history or review of diagnostic 

reports. While Dr. DeGrauw generally noted that he treated appellant for several years, the 

record does not contain medical examination findings and reports which actually establish the 

diagnosis of lower and upper back degenerative joint disease. He vaguely noted treatment and 

findings by neurology, orthopedics, and primary care physicians which were too numerous to 

document. The procedure manual provides that greater probative value is given to a medical 

opinion based on an actual examination. An opinion based on a cursory or incomplete 

examination will have less value compared to an opinion based on a more complete evaluation.12 

Dr. DeGrauw only generally noted that appellant engaged in repetitive pushing, lifting, 

pulling, bending, and twisting and failed to adequately describe the occupational duties alleged 

to have caused degenerative joint disease of the back. Moreover, his February 28, 2014 physical 

examination of the right and left lower extremity revealed normal strength, range of motion, and 

function. Dr. DeGrauw reported that even with normal examination findings, the neck, back, 

and shoulder were severely limited due to pain associated with arthritis. However, he failed to 

establish arthritis of the back as he has provided no support or objective evidence establishing 

this condition.13 

In his May 21, 2014 report, Dr. DeGrauw diagnosed chronic degenerative joint disease in 

multiple areas of the body including the lower back, upper back, neck, shoulders, wrists, and 

elbows. With respect to degenerative joint disease of the lower and upper back, he noted that 

appellant’s symptoms were present since 2002 with incidences stemming back to 1987. 

Dr. DeGrauw again failed to provide an adequate and detailed medical history and did not 

address why appellant’s complaints were not caused by a preexisting degenerative condition or 

nonoccupational injury. His general observation that repetitive lifting involved multiple aspects 

 11 See Robert Broome, 55 ECAB 339 (2004). 

12 Federal (FECA) Procedure Manual, Part 2 -- Claims, Developing and Evaluating Medical Evidence, Chapter 

2.810.6(a)(4) (September 2010). 

13 T.G., Docket No. 13-76 (issued March 22, 2013); C.F., Docket No. 08-1102 (issued October 10, 2008). 
7

of the body is speculative and equivocal in nature, providing only a vague inference of causal 

connection. Dr. DeGrauw’s report provided no discussion regarding whether preexisting 

degenerative joint disease had progressed beyond what might be expected from the natural 

progression of that condition.14 A well-rationalized opinion is particularly warranted when there 

is a history of a preexisting condition.15 While Dr. DeGrauw had some understanding of 

appellant’s employment duties,16 he failed to establish a firm medical diagnosis establishing a 

right leg, or back injury, and did not provide a rationalized opinion on causal relationship. Thus, 

his medical report does not constitute probative medical evidence because he fails to provide a 

clear diagnosis and does not adequately explain the cause of appellant’s injury.17 

The record contains no other medical reports documenting treatment of these conditions, 

making it unclear what diagnostic reports or examination findings Dr. DeGrauw utilized to 

ascertain the diagnoses provided. An explanation not supported by physical findings does not 

constitute a well-rationalized medical opinion.18 Dr. DeGrauw’s reports do not meet that 

standard and are insufficient to meet appellant’s burden of proof.19

The remaining medical evidence of record is also insufficient to establish appellant’s 

claim. Dr. Kleinsmith’s February 25, 2014 report is of no probative value as he provided no 

findings pertaining to the back or lower extremities as alleged by appellant in this occupational 

disease claim.20 The x-ray images of the cervical and lumbar spine are also of no probative value 

as they were not accompanied by a physician’s diagnostic report interpreting the findings.21 As 

noted above, the additional diagnoses provided by Dr. DeGrauw that do not relate to the right leg 

and lower back injuries alleged by appellant in this claim are of no probative value. It is 

appellant’s burden to specify the nature of his claim.22 

 14 R.E., Docket No. 14-868 (issued September 24, 2014). 

15 The Board has held that an opinion that a condition is causally related because the employee was asymptomatic 

before the injury is insufficient, without adequate rationale, to establish causal relationship. T.M., Docket No. 08-

975 (issued February 6, 2009); Michael S. Mina, 57 ECAB 379 (2006). 

16 The physician explained that appellant’s work as a sheet metal mechanic for the past 30 years involved lifting 

heavy items weighing 150 to 175 pounds, frequent bending over and stooping approximated at 80 degree angles for 

70 to 80 percent of the day, and frequent bending over using pneumatic bands to apply sheet metal. 

17 Ceferino L. Gonzales, 32 ECAB 1591 (1981). 

18 Supra note 12 at Chapter 2.810.6(a)(2). 

19 See L.M., Docket No. 14-973 (issued August 25, 2014); R.G., Docket No. 14-113 (issued April 25, 2014); 

K.M., Docket No. 13-1459 (issued December 5, 2013); A.J., Docket No. 12-548 (issued November 16, 2012). 

20 The Board notes that, at the March 11, 2015 hearing, appellant’s representative testified that he had a previous 

work-related shoulder injury for which he underwent surgery. The record before the Board contains no other 

information pertaining to this claim. 

21 The x-ray images also failed to identify a physician or date of study. See J.P., Docket No. 14-87 (issue 

March 14, 2014). 

22 O.S., Docket No. 13-438 (issued July 15, 2014). 
8

In the instant case, the record is without rationalized medical evidence establishing a 

diagnosed medical condition causally related to the accepted federal employment duties. OWCP 

advised appellant of the type of medical evidence required to establish his claim; however, he 

failed to submit such evidence. Thus, appellant has failed to meet his burden of proof. 

Appellant may submit additional evidence, together with a written request for 

reconsideration, to OWCP within one year of the Board’s merit decision, pursuant to 5 U.S.C. 

§ 8128(a) and 20 C.F.R. §§ 10.606 and 10.607. 

CONCLUSION 

The Board finds that appellant failed to meet his burden of proof to establish that he 

developed a right leg or back injury as a result of his federal employment duties. 

ORDER 

IT IS HEREBY ORDERED THAT the May 26, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: October 26, 2015 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board