United States Department of Labor 

Employees’ Compensation Appeals Board 

_________________________________________ 

B.R., Appellant 

and 

SOCIAL SECURITY ADMINISTRATION, 

Suisan City, CA, Employer 

___________________________________________

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Docket No. 16-0456 

Issued: April 25, 2016 

Appearances: Case Submitted on the Record 

Alan J. Shapiro, Esq., 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 January 11, 2016 appellant, through counsel, filed a timely appeal of a September 4, 

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 

causally related to an October 27, 2014 employment incident. 

FACTUAL HISTORY 

On October 27, 2014 appellant, then a 30-year-old service representative, filed a 

traumatic injury claim (Form CA-1) alleging that on October 27, 2014 at 7:45 a.m. she injured 

 1

 5 U.S.C. § 8101 et seq.
2

her left wrist and arm while moving her desk.2

 She stated that at that time she was wearing a left 

wrist brace and, as she tried to pull the name tag off her desk, some plastic snapped and her wrist 

was pulled and twisted. Appellant advised that her wrist was severely hurting. She stopped 

work on October 28, 2014. The employing establishment noted that the doctor placed her off 

work for 45 days. 

 In a November 13, 2014 letter, OWCP advised appellant that additional factual and 

medical evidence was needed. It informed appellant of the type of evidence needed to support 

her claim and requested that she submit such evidence within 30 days. 

Appellant provided several reports from Dr. Robert A. Gomez, a Board-certified 

orthopedic surgeon. In a November 12, 2014 report, Dr. Gomez noted that appellant presented 

with left shoulder, elbow, and wrist injuries that occurred on May 7, 2013 when she was moving 

office material from her old desk to a new desk and injured her left wrist trying to remove the 

name plate from her cubicle. He advised that she felt a pop and had immediate pain but was able 

to finish the workday. Appellant related that the next morning she awoke to find the left wrist 

and hand swollen. She saw an orthopedist the next day, was put in a thumb splint, and received 

follow-up care. He noted that she had a previous left wrist injection without benefit and was off 

work since her injury. The physician noted that she was complaining of left wrist, elbow, and 

shoulder pain and presented wearing a short-arm thumb brace with a forearm band for her lateral 

epicondylitis. Appellant denied any other history of previous injury or similar symptoms of the 

left wrist. She did have a prior history of right wrist first dorsal compartment release. The 

physician explained that her left wrist pain awakened her on a nightly basis and advised that she 

had difficulty with activities of daily living. Dr. Gomez indicated she took medication, and had a 

left wrist and shoulder injection, which did not help, although her current wrist brace helped. 

Left wrist findings included tenderness over the dorsal compartment, the lateral epicondyle, and 

the radial tunnel. She had mild pain with wrist extension against resistance and no pain with 

wrist flexion against resistance. The physician also determined that the left shoulder was tender 

over the anterior aspect of the acromion and the biceps tendon. Dr. Gomez diagnosed left wrist 

de Quervain’s tenosynovitis, left elbow lateral epicondylitis, radial tunnel syndrome, and left 

shoulder impingement syndrome with associated biceps tendinitis. He advised that a previous 

physician performed a left wrist first dorsal compartment injection without benefit. The 

physician recommended a first dorsal compartment release at the wrist. He also indicated that 

appellant was advised to stop wearing the forearm band as it typically exacerbated radial tunnel 

syndrome. Regarding the elbow, he recommended extensor carpi radialis brevis (ECRB) 

debridement and radial tunnel release. Dr. Gomez also diagnosed left shoulder impingement 

syndrome with associated biceps tendinitis and explained that she would eventually require an 

arthroscopic subacromial decompression and biceps tendon release versus resection. He advised 

that authorization for these procedures would be requested. 

In a November 24, 2014 report, Dr. Gomez noted that appellant was totally disabled for 

the period from October 28 to December 16, 2014. He indicated he would be requesting 

authorization for first dorsal compartment release at the wrist, ECRB debridement, and radial 

 2

 The original claim form indicated a September 27, 2014 date of injury. However, this was amended to 

October 27, 2014. 
3

tunnel release of the left elbow. The physician opined that her left shoulder and wrist injuries 

occurred on May 7, 2013 when she was moving office material from her old desk to a new desk. 

Dr. Gomez explained that she injured her left wrist trying to remove the name plate from her 

cubicle, felt a pop and had immediate pain. He diagnosed left wrist de Quervain’s tenosynovitis, 

left elbow lateral epicondylitis, radial tunnel syndrome, biceps tendinitis, and coracoids 

impingement. 

By decision dated December 12, 2014, OWCP denied appellant’s claim because she did 

not establish an injury as alleged as the factual component had not been met. It noted that 

appellant did not respond to the request for factual information. OWCP also noted that she had 

indicated that she was wearing a left wrist brace and was claiming a left wrist injury and that she 

did not explain why she was working prior to her start time. OWCP further found that the 

medical evidence was insufficient as the date of injury was referred to as May 7, 2013 and not 

October 27, 2014 as indicated in her claim. Appellant was advised that if she was pursuing an 

injury due to an incident of May 7, 2013,3

 she should pursue the matter under that claim No. 

xxxxxx664.4

 

On December 30, 2014 OWCP received appellant’s request for a telephonic hearing 

before an OWCP hearing representative, which was held on July 14, 2015. She reiterated that 

the date of injury was October 27, 2014. 

In a December 15, 2014 treatment note, Dr. Gomez advised that appellant returned for 

reevaluation of her left upper extremity. He indicated that they were awaiting authorization and 

she continued to have severe left upper extremity pain with daily use and was unable to tolerate 

any anti-inflammatory medications. The physician advised that she took Tylenol for pain and 

used ice and wrist braces. He noted that the current magnetic resonance imaging (MRI) scans of 

the left wrist were unremarkable as there was a small subchondral cyst on the lunate. Dr. Gomez 

found tendinosis of the common extensor region on the left elbow and advised that she remain 

off work. OWCP also received copies of prior reports. 

In a January 7, 2015 treatment note, Dr. Gomez indicated that appellant returned for reevaluation. He repeated his previous diagnoses and noted that her claim was denied. The 

physician indicated that he would try to proceed with surgery through her regular insurance. 

On January 8, 2015 OWCP received appellant’s questionnaire, which was dated 

December 29, 2014. She noted that she was told by management that she had a new injury. She 

also indicated that her work start time was flexible from 7:00 a.m. to 9:00 a.m. and she was 

working at the time of her injury. 

In a February 13, 2015 duty status report (Form CA-17), Dr. Gomez release appellant to 

work with restrictions to include no use of the left hand. 

 3

 The Board notes that, although OWCP actually included a second date of May 7, 2014, this appears to be a 

typographical error as it initially referred to May 7, 2013. 

4

 Claim number xxxxxx664 is not before the Board on the present appeal. 
4

By decision dated September 4, 2015, an OWCP hearing representative affirmed the 

December 12, 2014 decision. She found that the factual component of appellant’s claim was 

accepted. However, the hearing representative further found that the medical evidence was 

insufficient as there was no rationale to support causal relationship.

LEGAL PRECEDENT 

An employee seeking benefits under FECA has the burden of proof to establish 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 timely filed within the 

applicable time limitation period of FECA,5 and that an injury was sustained in the performance 

of duty.6 These are the essential elements of each compensation claim, regardless of whether the 

claim is predicated upon a traumatic injury or an occupational disease.7

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether the fact of injury has been established. 

There are two components involved in establishing the fact of injury. First, the employee must 

submit sufficient evidence to establish that he or she actually experienced the employment 

incident at the time, place, and in the manner alleged.8

 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.9 

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 

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

specific employment factors identified by the claimant.10

ANALYSIS 

In this case, OWCP has accepted that on October 27, 2014 the claimed incident occurred 

as alleged. Therefore, the Board finds that the first component of fact of injury, the claimed 

incident, is established. 

However, with regard to the medical evidence, the Board finds that it is insufficiently 

rationalized to establish the second component of fact of injury, that the employment incident 

caused an injury. The medical evidence contains no reasoned explanation of how the specific 

 5 Joe D. Cameron, 41 ECAB 153 (1989). 

6 James E. Chadden, Sr., 40 ECAB 312 (1988). 

7 Delores C. Ellyett, 41 ECAB 992 (1990). 

8 Julie B. Hawkins, 38 ECAB 393, 396 (1987). 

9 Id. For a definition of the term “traumatic injury,” see 20 C.F.R. § 10.5(ee). 

10 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 
5

employment incident on October 27, 2014 caused or aggravated an injury.11 The Board notes 

that this is particularly important in light of the reference to pre-existing conditions to include the 

fact that she was already wearing a left wrist brace at the time of the incident. 

Appellant submitted several reports from Dr. Gomez. However, these reports are of 

limited value as they contain an inaccurate history of injury. The Board notes that appellant 

clearly indicated that the date of injury was October 27, 2014. However, Dr. Gomez referred to 

the injury date as May 7, 2013 in both his November 12 and 24, 2014 reports. He also 

referenced preexisting conditions and her prior treatment. It is well established that medical 

reports must be based on a complete and accurate factual and medical background, and medical 

opinions based on an incomplete or inaccurate history are of little probative value.12 His 

subsequent reports contained diagnoses and requests for surgeries, but there was no accurate 

history of injury provided. He did not offer any opinion with regard to a work injury occurring 

on October 27, 2014 involving the movement of her desk. 

Other reports are also of limited probative value on the relevant issue as they do not 

contain an accurate history of injury or an opinion on causal relationship. 

Because the medical reports submitted by appellant do not address how the October 27, 

2014 activities at work caused or aggravated a left wrist or arm condition, these reports are of 

limited probative value13 and are insufficient to establish that the October 27, 2014 employment 

incident caused or aggravated a specific injury. Therefore, appellant has not met her burden of 

proof. 

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 meet her burden of proof to establish a traumatic 

injury causally to an October 27, 2014 employment incident. 

 11 See George Randolph Taylor, 6 ECAB 986, 988 (1954) (where the Board found that a medical opinion not 

fortified by medical rationale is of little probative value). 

12 Douglas M. McQuaid, 52 ECAB 382 (2001). 

13 See Linda I. Sprague, 48 ECAB 386, 389-90 (1997). 
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ORDER 

IT IS HEREBY ORDERED THAT the September 4, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: April 25, 2016 

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