United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

C.B., Appellant 

and 

DEPARTMENT OF HOMELAND SECURITY, 

CITIZENSHIP & IMMIGRATION SERVICES, 

Los Angeles, CA, Employer 

__________________________________________ 

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Docket No. 15-1350 

Issued: March 18, 2016 

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 

ALEC J. KOROMILAS, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On June 1, 2015 appellant filed a timely appeal from a May 19, 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. 

ISSUE 

The issue is whether appellant met her burden of proof to establish a traumatic injury in 

the performance of duty on March 12, 2013. 

FACTUAL HISTORY 

On April 10, 2013 appellant, then a 44-year-old immigration services officer, filed a 

traumatic injury claim (Form CA-1) alleging that on March 12, 2013 she injured her right 

 1

 5 U.S.C. § 8101 et seq. 
2

shoulder and right side of her neck when she carried a heavy file and opened a heavy door. She 

stopped work on March 12, 2013 and returned to work on March 13, 2013. The employing 

establishment noted that it had not received notification of this injury until the date of filing 

appellant’s claim. 

In a report dated March 15, 2013, Dr. James Mitchner, Board-certified in occupational 

medicine, diagnosed appellant with a shoulder strain of the right trapezius muscle. Appellant 

indicated that she had developed right trapezius pain from performing duties of her employment, 

and that “over the last few months pain has developed in the same area as before.” Dr. Mitchner 

further noted that appellant denied any direct trauma or known new injury. He noted that she 

had job responsibilities of forceful grasping for up to 6+ hours per day; repetitive bending, 

twisting, and squatting; and prolonged computer work or typing for up to 6+ hours per day. 

Dr. Mitchner recommended restricted work duties for the period March 15 through 22, 2013 of 

reaching above her shoulder for no more than 20 percent of her shift and no lifting over 10 

pounds. He recommended physical therapy, which OWCP authorized on June 26, 2013. 

In a work status report dated March 15, 2013, Dr. Mitchner extended appellant’s work 

restrictions through March 22, 2013 and noted a date of injury of July 27, 2012. In subsequent 

reports, he extended her restrictions through June 27, 2013 and listed the date of injury as 

July 28, 2012 or March 12, 2013. 

In a report dated June 27, 2013, Dr. Mitchner stated that appellant’s condition had not 

resolved and that activities of daily living requiring reaching above the shoulder level were 

painful and restricted. He noted that appellant had a history of a previous right shoulder injury 

and extended her work restrictions through July 11, 2013. 

By letter dated July 12, 2013, OWCP notified appellant that her claim had been opened 

for formal adjudication at her request. It stated that she had not submitted sufficient medical 

evidence to establish that her injury resulted from activities of her federal employment. OWCP 

afforded appellant 30 days to submit additional evidence and to respond to its inquiries. In 

particular, it requested clarification as to whether she was filing a claim for occupational disease 

or traumatic injury. 

On July 12, 2013 appellant told Dr. Mitchner that her shoulder and neck began to bother 

her on March 12, 2013. She had pushed open a heavy door for a customer, after which she 

began to feel pain in her right shoulder and neck. Dr. Mitchner stated, “The mechanism of action 

of the patient pushing open a heavy door on March 12, 2013 caused [appellant’s] right shoulder 

and neck injuries.” He recommended a magnetic resonance imaging (MRI) scan of appellant’s 

right shoulder for persistent pain that had not resolved with physical therapy, activity restriction, 

or a home exercise program, in order to rule out the possibility of a rotator cuff tear. 

Dr. Mitchner extended her work restrictions through August 2, 2013. 

By decision dated August 13, 2013, OWCP denied appellant’s claim for compensation. 

It found that she had not submitted sufficient evidence to establish that the event occurred as 

described, because it was not clear whether she was filing a claim for traumatic injury or 

occupational disease. OWCP noted that the medical reports were contradictory as to how 
3

appellant’s injury occurred and that it had not received a response to its inquiry to clarify the 

mechanism of injury. 

In a report dated August 2, 2013, Dr. Mitchner extended appellant’s work restrictions 

through August 23, 2013. 

On September 11, 2013 appellant requested an oral hearing before an OWCP hearing 

representative. The hearing was held on March 13, 2014. The hearing officer noted that 

appellant had nine prior claims for work injuries or conditions and one subsequent claim for an 

employment injury or condition, several of which involved injuries to the right shoulder or neck. 

Appellant stated that she had not received OWCP’s July 12, 2013 development letter and that it 

might have been taken by a neighbor. She explained that on March 12, 2013 she opened a heavy 

door for a customer to enter a work area, using her right hand and arm. Shortly afterward, 

appellant’s shoulder began to bother her. She stated that she then notified her manager that she 

was going to leave for the day as she injured her shoulder. Appellant told another manager that 

she had possibly reinjured her arm because she had injured the same shoulder the previous year. 

She noted that in July 2012 she had been diagnosed with a work-related right shoulder sprain or 

strain, which eventually resolved. The hearing representative noted that Dr. Mitchner’s reports 

were inconsistent with appellant’s history of injury, and that she would need for him to reconcile 

that inconsistency. She stated that it appeared that appellant was not claiming a recurrence, but a 

new traumatic injury. Appellant noted that she had asked OWCP to formally adjudicate the 

claim so that she could buy back leave that she had used to attend physical therapy appointments. 

Appellant submitted a narrative statement in which she reiterated the timeline of her 

interactions with OWCP and her physician. The statement was consistent with and substantially 

the same as her testimony at the oral hearing. Appellant also resubmitted Dr. Mitchner’s 

previous reports. 

On April 12, 2013 Dr. Mitchner completed a “first report of occupational injury for 

appellant’s condition.” He noted both that appellant “denied any prior injury or disability 

associated with the above claimed body parts” and that appellant had a history of a previous right 

shoulder injury. Dr. Mitchner stated that his findings were consistent with appellant’s account of 

injury. 

In a report dated August 2, 2013, Dr. Mitchner stated that appellant had mild right 

shoulder pain that periodically traveled down the neck and arm. He noted that she had a 

previous right shoulder injury and listed her date of injury as March 12, 2013. Dr. Mitchner 

extended her work restrictions through August 23, 2013. 

By decision dated May 20, 2014, the hearing representative affirmed OWCP’s 

August 13, 2013 decision. However, she modified the basis for denial, finding that appellant had 

not submitted sufficient medical evidence to establish that the incident of March 12, 2013 caused 

appellant’s right shoulder and neck condition. 

On February 18, 2015 appellant requested reconsideration of OWCP’s May 20, 2014 

decision. With her request, she submitted a statement from a supervisor noting that appellant 
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had informed him that her shoulder was bothering her on March 12, 2013 and that she would be 

taking the rest of the day off. 

In a report dated December 11, 2014, Dr. Mitchner responded to the hearing 

representative’s decision. He stated: 

“What I can say in this case is that the patient denies any outside activities that 

could have injured her right shoulder.... To the best the patient can determine she 

believes she injured her right shoulder while pushing a door open for a customer 

against firm resistance. This mechanism is not uncommon if the resistance is 

sufficient and the patient’s arm is extended while pushing the door open leaving 

the shoulder joint vulnerable to injury due to the leverage the resistance causes 

across the distance of an extended arm on the shoulder. Much the same way [a] 

floor jack easily raises the car due to the extended leverage arm, an extended arm 

pushing open a door with sufficient resistance can strain the shoulder tendons and 

ligaments as well as a trapezius muscle which connects the shoulder to the base of 

the neck. In questioning the patient, she initially felt the injury that occurred on 

March 12, 2013 was an aggravation/flare up of a previous shoulder injury. 

However, in retrospect [appellant] believes she made a mistake and filed the 

wrong type of injury form. She believes this March 12, 2013 injury to her right 

shoulder was a new incident. I am recommending the patient’s right shoulder and 

trapezius strain be accepted and an MRI [scan] performed to rule out the 

possibility of a rotator cuff tear. If the patient’s right shoulder sustained a rotator 

cuff tear, patients are often still symptomatic until further treatment is obtained. 

If the right shoulder MRI [scan] reveals there is no rotator cuff tear then this 

March 15, 2013 injury can be closed.” 

 By decision dated May 19, 2015, OWCP reviewed the merits of appellant’s claim and 

denied modification of their previous decision. It noted that Dr. Mitchner had not yet offered an 

opinion of his own regarding the causation of appellant’s injury, but instead had relied only upon 

what appellant believed. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA2

 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; that an injury was sustained while 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.3 These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated on a traumatic injury or an occupational disease.4

 2 Supra note 1. 

3 C.S., Docket No. 08-1585 (issued March 3, 2009); Bonnie A. Contreras, 57 ECAB 364, 366 (2006). 

4 S.P., 59 ECAB 184, 188 (2007); Joe D. Cameron, 41 ECAB 153, 157 (1989). 
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To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty it must first be determined whether a fact of injury has been established.5

 

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.6

 Second, the employee must 

submit sufficient evidence, generally only in the form of medical evidence, to establish that the 

employment incident caused a personal injury.7

The claimant has the burden of establishing by the weight of reliable, probative and 

substantial evidence that the condition for which compensation is sought is causally related to a 

specific employment incident or to specific conditions of employment.8

 An award of 

compensation may not be based on appellant’s belief of causal relationship. Neither the mere 

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 

sufficient to establish a causal relationship.9

Causal relationship is a medical issue and the medical evidence generally required to 

establish causal relationship is rationalized medical opinion evidence.10 Rationalized medical 

opinion evidence is medical evidence which includes a physician’s rationalized opinion on 

whether there is a causal relationship between the employee’s diagnosed condition and 

compensable employment factors.11 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 the employee.12

ANALYSIS 

The Board finds that the medical evidence submitted by appellant is insufficient to 

establish that the incident of March 12, 2013 caused or aggravated appellant’s diagnosed medical 

conditions. 

In the initial report OWCP received from Dr. Mitchner, dated March 15, 2013, he 

indicated that appellant had experienced shoulder pain over the past few months, and that 

 5 B.F., Docket No. 09-60 (issued March 17, 2009); Bonnie A. Contreras, supra note 3 at n.5. 

6 D.B., 58 ECAB 464, 466 (2007); David Apgar, 57 ECAB 137, 140 (2005). 

7 C.B., Docket No. 08-1583 (issued December 9, 2008); D.G., 59 ECAB 734, 737 (2008); Bonnie A. Contreras, 

supra note 3 at n.5. 

8 Roma A. Mortenson-Kindschi, 57 ECAB 418, 428 n.37 (2006); Katherine J. Friday, 47 ECAB 591, 594 (1996). 

9 P.K., Docket No. 08-2551 (issued June 2, 2009); Dennis M. Mascarenas, 49 ECAB 215, 218 (1997). 

10 Y.J., Docket No. 08-1167 (issued October 7, 2008); A.D., 58 ECAB 149, 155-56 (2006); D’Wayne Avila, 57 

ECAB 642, 649 (2006). 

11 J.J., Docket No. 09-27 (issued February 10, 2009); Michael S. Mina, 57 ECAB 379, 384 (2006). 

12 I.J., 59 ECAB 408, 415 (2008); Victor J. Woodhams, 41 ECAB 345, 352 (1989). 
6

appellant had denied any direct trauma or new injury. Appellant thereafter submitted two reports 

from Dr. Mitchner containing his opinion on the causal relationship between her diagnosed right 

shoulder and neck conditions and the incident of March 12, 2013. In a July 12, 2013 report, 

Dr. Mitchner stated, “The mechanism of action of the patient pushing open a heavy door on 

March 12, 2013 caused [appellant’s] right shoulder and neck injuries.” This opinion is not 

rationalized, as it does not contain any medical or biomechanical explanation regarding how he 

arrived at that conclusion. Instead it merely states Dr. Mitchner’s opinion, without supportive 

medical reasoning. Dr. Mitchner also does not explain why his earlier report had referred to 

prior months of shoulder pain, and no new injury. Medical evidence submitted to support a 

claim for compensation should reflect a correct history, and the physician should offer a 

medically sound explanation of how the claimed work event caused or aggravated the claimed 

condition.13 Lacking such an explanation, Dr. Mitchner’s July 12, 2013 report is not sufficient to 

establish a causal relationship between the events of March 12, 2013 and appellant’s diagnosed 

conditions. 

In a report dated December 11, 2014, Dr. Mitchner communicated appellant’s opinions as 

to the cause of her conditions and noted that the type of injury claimed by appellant was “not 

uncommon” if the circumstances of the alleged injury included sufficient resistance while 

pushing a door open. Dr. Mitchner’s December 11, 2014 report does not contain language of 

reasonable medical certainty. Rather, it merely paraphrases appellant’s statements and beliefs as 

to the cause of her conditions and states that the type of injury claimed by appellant is “not 

uncommon” under the described circumstances. Stating that an injury is “not uncommon” under 

a given set of circumstances does not directly address the specific circumstances of the present 

claim and does not express reasonable medical certainty -- it is, instead, equivocal and 

speculative language concerning the cause of her conditions. The opinion of a physician 

supporting causal relationship must be one of reasonable medical certainty that the condition for 

which compensation is claimed is causally related to her federal employment; and such 

relationship must be supported with affirmative evidence, explained by medical rationale and be 

based upon a complete and accurate medical and factual background of the claimant.14 As such, 

Dr. Mitchner’s reports are insufficient to establish appellant’s claim for right neck and shoulder 

conditions. 

As appellant has not submitted any rationalized medical evidence to support her 

allegation that she sustained an injury causally related to a March 12, 2013 employment incident, 

she has not met her burden of proof to establish a 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. 

 13 D.D., Docket No. 13-1517 (issued April 14, 2014). 

14 A.D., 58 ECAB 149 (2006). 
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CONCLUSION 

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

injury in the performance of duty on March 12, 2013. 

ORDER 

IT IS HEREBY ORDERED THAT the May 19, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed.15

Issued: March 18, 2016 

Washington, DC 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 15 James A. Haynes, Alternate Judge, participated in the original decision but was no longer a member of the 

Board effective November 16, 2015.