United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

S.H., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Dumfries, VA, Employer 

__________________________________________ 

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Docket No. 16-0508 

Issued: July 5, 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 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

COLLEEN DUFFY KIKO, Judge 

JURISDICTION 

On January 22, 2016 appellant, through counsel, filed a timely appeal from a 

December 3, 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. 

ISSUES 

The issues are: (1) whether appellant has met her burden of proof to establish a 

recurrence of disability from March 25 to April 10, 2013 due to accepted right upper extremity 

conditions; and (2) whether appellant has met her burden of proof to establish that she sustained 

reflex sympathetic dystrophy syndrome or complex regional pain syndrome of the right upper 

extremity, consequential to accepted upper extremity conditions. 

 1

 5 U.S.C. § 8101 et seq. 
2

FACTUAL HISTORY 

OWCP accepted that on April 29, 2010 appellant, then a 41-year-old rural carrier, 

sustained bilateral carpal tunnel syndrome, enesopathy of the elbow region, and other peripheral 

enesopathies.2 Following intermittent absences, she stopped work on August 16, 2010. OWCP 

paid wage-loss compensation from October 1 through November 27, 2010 and continuing.3 

December 27, 2010 electromyography (EMG) and nerve conduction velocity (NCV) 

studies demonstrated bilateral carpal tunnel syndrome and mild bilateral cubital tunnel 

syndrome.4

 On March 14, 2011 Dr. Ivica Ducic, an attending Board-certified plastic surgeon, 

performed right ulnar nerve neurolysis at the elbow, right partial medial epicondylectomy, and 

right endoscopic carpal tunnel release. Appellant received compensation for work absences 

through January 14, 2012.5

Dr. Ducic submitted January 24 and October 3, 2012 reports diagnosing pain and 

paresthesias of the right arm. He prescribed medication.6

Dr. Suneetha Budampati, an attending Board-certified physiatrist, provided June 24 and 

October 24, 2012 reports diagnosing chronic pain syndrome, carpal tunnel syndrome, and ulnar 

nerve entrapment of the right upper extremity. She prescribed medication. 

Following a rehabilitation effort, appellant accepted a modified-duty assignment on 

January 22, 2013 and returned to work that day. She stopped work a few hours into her shift. 

Appellant received emergency room treatment on January 22, 2013 from Dr. Lisa K. Malloy, an 

attending Board-certified family practitioner, who diagnosed brachial neuritis or radiculitis. A 

January 22, 2013 venous Doppler study of the right upper extremity was normal. OWCP 

accepted a recurrence of disability from January 23 to March 24, 2013 due to accepted bilateral 

carpal tunnel syndrome, enesopathy of the right elbow, and other peripheral enesopathies. 

 2

 By decision dated August 3, 2010, OWCP denied appellant’s claim for bilateral carpal tunnel syndrome, finding 

that causal relationship was not established. Appellant requested a review of the written record. By decision dated 

and finalized November 18, 2010, an OWCP hearing representative reversed OWCP’s August 3, 2010 decision and 

accepted bilateral carpal tunnel syndrome as work related. 

3

 OWCP initially denied appellant’s claims for wage-loss compensation by decision dated October 27, 2011, 

based on a lack of medical evidence. Appellant requested reconsideration. By decision dated December 28, 2011, 

OWCP affirmed the October 27, 2011 decision. Appellant requested reconsideration on March 29, 2012. By 

decision dated November 2, 2012, OWCP vacated the prior decisions and approved appellant’s claims for wage-loss 

compensation. 

4

 In reports from August 16, 2010 to April 11, 2011, Dr. Richard L. Layfield, III, diagnosed a left wrist 

sprain/strain. Appellant participated in physical therapy from January through September, 2011. 

5

 On October 5, 2011 the employing establishment offered appellant a modified-duty assignment. Appellant 

refused the offer on October 5, 2011, as it required lifting 10 pounds, whereas her physicians limited her to lifting 

five pounds. On October 24, 2011 Dr. Ducic opined that the offered position exceeded her physical limitations. 

6

 June 24, 2012 EMG and NCV studies showed bilateral carpal tunnel syndrome, right greater than left, mild left 

cubital tunnel syndrome, and improvement in right median nerve conduction after decompression. 
3

Dr. Naurang S. Gill, an attending neurologist, held appellant off work from February 6 to 

March 31, 2013 due bilateral carpal tunnel syndrome and upper extremity neuropathies. He 

ordered February 11, 2013 EMG and NCV studies, which demonstrated bilateral median nerve 

entrapment consistent with carpal tunnel syndrome, right greater than left. Dr. Gill released 

appellant to work as of March 25, 2013. In a March 25, 2013 report, Dr. Christopher G. 

Scharenbrock, an attending physician Board-certified in emergency medicine, released appellant 

to light duty as of March 26, 2013. He restricted lifting to five pounds through March 30, 2013. 

Appellant stopped work on March 25, 2013 and remained off work through 

April 8, 2013. The employing establishment noted that she was on full duty as of 

March 25, 2013. Appellant worked 1 hour and 15 minutes, then stopped work, asserting that she 

needed to seek emergency room treatment for right hand pain. 

Dr. Ashish Shanbhag, an attending Board-certified physiatrist, released appellant to 

sedentary duty on April 3, 2013. He submitted reports through July 19, 2013 diagnosing 

complex regional pain syndrome in the median and ulnar nerve distributions, unspecified reflex 

sympathetic dystrophy, carpal tunnel syndrome, ulnar nerve impairment, and chronic pain 

syndrome of mixed etiology. 

In an April 5, 2013 letter, the employing establishment advised appellant that there was 

no sedentary work available within her medical restrictions. 

In an April 9, 2013 letter, appellant requested that OWCP expand her claim to accept 

reflex sympathetic dystrophy syndrome/complex regional pain syndrome of the right upper 

extremity. She presented to a hospital emergency room on April 10, 2013. Nurses’ notes 

indicate that appellant was seen by a pain clinic and that her medications were changed. 

On April 24, 2013 appellant claimed a recurrence of disability from March 25 to 

April 10, 2013 (Form CA-2a). She asserted that after she returned to full-duty work on 

March 25, 2013 she had a flare-up of right carpal tunnel syndrome, ulnar nerve pain, swelling, 

and color changes of the right hand. Appellant attributed the flare-up to repetitive hand and arm 

movements while casing mail and lifting mail containers.7

 On July 25, 2013 OWCP advised her 

of the additional evidence needed to establish her claim, including a statement from her 

physician explaining why the accepted conditions or other work factors would disable her for 

work for the claimed period. It afforded appellant 30 days to submit such evidence. 

June 14, 2013 x-rays, bone scans, and venous testing of the upper extremity were normal. 

An OWCP medical adviser opined on July 6, 2013 that the test for reflex sympathetic dystrophy 

syndrome/complex regional pain syndrome was normal. 

Appellant submitted an August 12, 2013 statement, explaining that, while on regular duty 

with a lifting restriction, she had a flare-up of bilateral hand and arm pain. She asserted that 

repetitive arm motions at work caused nerve damage. 

 7

 The employing establishment advised that appellant was offered limited-duty assignments, but she turned them 

down. 
4

On August 16, 2013 Dr. Malloy provided a history of injury and treatment, noting 

appellant’s complaints of pain and paresthesias in her right hand and arm. She diagnosed 

unspecified reflex sympathetic dystrophy, carpal tunnel syndrome, ulnar nerve impairment, and 

chronic pain syndrome of mixed etiology. Dr. Malloy prescribed medication. 

By decision dated September 13, 2013, OWCP denied appellant’s claim for a recurrence 

of disability from March 25 to April 10, 2013, finding that the medical evidence of record was 

insufficient to establish that the accepted conditions disabled her from work on the claimed 

dates. It further found that she had not established reflex sympathetic dystrophy syndrome or 

complex regional pain syndrome due to the accepted conditions. 

Counsel requested a telephonic hearing, held March 19, 2014. At the hearing, appellant 

contended that she was disabled for work from March 25 to April 10, 2013 due to a combination 

of accepted carpal tunnel syndrome and enesopathy, and reflex sympathetic dystrophy syndrome. 

She asserted that she sustained reflex sympathetic dystrophy syndrome as a consequence of the 

accepted bilateral conditions. Appellant submitted additional evidence. 

Dr. Malloy provided reports from September 26, 2013 to April 17, 2014, diagnosed 

neuritis, and complex regional pain syndrome in the ulnar and median nerve distributions of the 

right forearm, with “minimal symptomatology.”8

 In an October 15, 2013 report, Dr. Ducic 

diagnosed “right arm pain.” 

In a June 3, 2014 decision, an OWCP hearing representative affirmed the September 13, 

2013 decision, finding that the additional medical evidence submitted was insufficiently 

rationalized to expand the claim to include complex regional pain syndrome/reflex sympathetic 

dystrophy consequential to the accepted bilateral carpal tunnel syndrome, and upper extremity 

enesopathies. The hearing representative further found that the medical evidence of record did 

not establish that disability from work on March 25 and April 10, 2013, either due to the 

accepted conditions or reflex sympathetic dystrophy. 

Counsel requested reconsideration by letter dated July 19, 2014. He submitted additional 

evidence. Dr. Malloy noted in a September 8, 2014 report that appellant was formally diagnosed 

with reflex sympathetic dystrophy/complex regional pain syndrome, and required treatment by a 

neurologist. 

Dr. Jason S. Wong, an attending neurologist, provided a July 16, 2014 report relating a 

history of injury and treatment. He noted appellant’s complaints of numbness and paresthesias 

in the right upper extremity of unknown etiology. Dr. Wong prescribed a transcutaneous 

electrical stimulation (TENS) unit. Also submitted were occupational therapy notes. 

 8

 On February 28, 2014 appellant claimed a schedule award. Counsel obtained an impairment rating from 

Dr. Stuart J. Goodman, a Board-certified neurologist, who opined on February 24, 2014 that appellant had attained 

maximum medical improvement. He assessed 18 percent impairment of the right upper extremity according to the 

sixth edition of the American Medical Association, Guides to the Evaluation of Permanent Impairment, based on 

ulnar and median nerve deficits. 
5

By decision dated October 16, 2014, OWCP denied modification of the June 3, 2014 

decision, finding that appellant had not submitted sufficient medical evidence to establish 

disability for work from March 25 to April 10, 2013 due to consequence of the accepted 

conditions.9

In a September 8, 2015 letter, counsel again requested reconsideration. He submitted 

March 28 and June 26, 2014 reports from Dr. Wong diagnosing chronic nerve damage of the 

right arm and holding appellant off work. On January 6, 2015 Dr. Wong opined that complex 

regional pain syndrome was “the most likely cause” of her right arm symptoms. In a July 11, 

2015 report, he diagnosed type 1 complex regional pain syndrome caused by “continuous, 

repetitive activity using her hands while working for [the employing establishment] for years.” 

The report contains a preprinted paragraph attributing the diagnosed condition named on the 

form to the work activities described. Dr. Wong did not provide his own analysis of causal 

relationship.10

By decision dated December 3, 2015, OWCP denied modification of the October 16, 

2014 decision, finding that appellant had failed to establish a causal relationship between reflex 

sympathetic dystrophy syndrome and the accepted upper extremity conditions. It further found 

that she had not submitted sufficient medical evidence to establish disability for work from 

March 25 to April 10, 2013 due to accepted right upper extremity conditions. 

LEGAL PRECEDENT -- ISSUE 1 

OWCP’s implementing regulations define a recurrence of disability as “an inability to 

work after an employee has returned to work, caused by a spontaneous change in a medical 

condition which has resulted from a previous injury or illness without an intervening injury or 

new exposure to the work environment that caused the illness.”11 This term also means an 

inability to work when a light-duty assignment made specifically to accommodate an employee’s 

physical limitations due to his or her work-related injury or illness is withdrawn (except when 

such withdrawal occurs for reasons of misconduct, nonperformance of job duties, or a reductionin-force), or when the physical requirements of such an assignment are altered so that they 

exceed his or her established physical limitations.12 

When an appellant claims a recurrence of disability due to an accepted employment-related 

injury, he or she has the burden of establishing by the weight of reliable, probative, and substantial 

evidence that the recurrence of disability is causally related to the original injury. This burden 

includes the necessity of furnishing evidence from a qualified physician, who, on the basis of a 

 9

 In a November 14, 2014 letter, appellant advised OWCP that she began a seasonal retail job at $9.00 an hour. 

10 Dr. Robert Macht, an attending general surgeon, submitted a January 13, 2015 impairment rating pursuant to 

appellant’s schedule award claim. He did not diagnose complex regional pain syndrome or address causal 

relationship. 

11 20 C.F.R. § 10.5(x); Federal (FECA) Procedure Manual, Part 2 -- Claims, Recurrences, Chapter 2.1500.2.b 

(June 2013). See also Philip L. Barnes, 55 ECAB 426 (2004). 

12 Id. at § 10.5(x).
6

complete and accurate factual and medical history, concludes that the condition is causally related 

to the employment injury. Moreover, sound medical reasoning must support the physician’s 

conclusion.13 An award of compensation may not be based on surmise, conjecture or speculation 

or on appellant’s unsupported belief of causal relation.14

ANALYSIS -- ISSUE 1 

OWCP accepted that appellant sustained bilateral carpal tunnel syndrome, enesopathy of 

the right elbow, and other peripheral enesopathies. Appellant was off work from August 16, 

2010 through January 14, 2012 and thereafter. Following a brief return to work in January 2013, 

she remained off work through March 25, 2013, when she returned to full-duty work with a 

temporary lifting limitation through March 30, 2013. Appellant again stopped work on 

March 25, 2013 and claimed a recurrence of disability through April 10, 2013. The employing 

establishment advised that it had made available light-duty work. 

Appellant has the burden of providing sufficient evidence, including rationalized medical 

evidence, to establish the causal relationship asserted between the accepted right upper extremity 

conditions, and a spontaneous worsening of her condition as claimed.15 However, she attributed 

a flare-up of right arm and hand symptoms to casing mail and lifting containers of mail at work 

on March 25, 2013. Appellant thus identified an intervening cause, breaking the chain of 

causation from the original injury.16 This effectively negates her claim for a recurrence of 

disability. 

Additionally, appellant’s physicians did not opine that she was disabled from work for 

the claimed period. Dr. Gill, an attending neurologist, released appellant to work as of 

March 25, 2013. Dr. Scharenbrock, an attending physician Board-certified in emergency 

medicine, found appellant able to work as of March 26, 2013. Dr. Shanbhag found appellant 

able to perform sedentary duty as of April 3, 2015, but did not explain the reasoning behind this 

limitation. 

OWCP advised appellant in a July 25, 2013 letter of the type of evidence needed to 

establish her claim for a recurrence of disability. As appellant did not submit such evidence, it 

properly issued its December 3, 2015 decision denying her recurrence claim. 

On appeal counsel asserts that OWCP’s December 3, 2015 decision was not rationalized 

and did not explain how the decision was reached. He contends that it appears that OWCP did 

not consider any evidence appellant submitted. As set forth above, appellant did not submit 

 13 Ricky S. Storms, 52 ECAB 349 (2001). 

14 Alfredo Rodriguez, 47 ECAB 437 (1996). 

15 Supra note 13. 

16 See Carlos A. Marrero, 50 ECAB 117 (1998) (the Board found that the claimant’s use of an exercise machine 

constituted an intervening cause of appellant’s disability and thus OWCP properly denied appellant’s claim for 

recurrence of disability); Clement Jay After Buffalo, 45 ECAB 707 (1994) (the Board found that the claimant’s knee 

injury sustained while playing basketball broke the legal chain of causation from an accepted knee injury sustained 

in the performance of his duties as a firefighter). 
7

sufficient rationalized medical evidence to establish that she was disabled for work from 

March 25 to April 10, 2013. 

LEGAL PRECEDENT -- ISSUE 2 

It is an accepted principle of workers’ compensation law that when the primary injury is 

shown to have arisen out of and in the course of employment, every natural consequence that 

flows from the injury is deemed to arise out of the employment, unless it is the result of an 

independent intervening cause which is attributable to the employee’s own intentional conduct. 

The Board has held that, once the work-connected character of any injury has been established, 

the subsequent progression of that condition remains compensable so long as the worsening is 

not shown to have been produced by an independent nonindustrial cause and so long as it is clear 

that the real operative factor is the progression of the compensable injury, associated with an 

exertion that in itself would not be unreasonable under the circumstances.17

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

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

complete factual and medical background, showing causal relationship. Rationalized medical 

evidence is evidence which relates a work incident or factors of employment to a claimant’s 

condition, with stated reasons of a physician. The opinion must be one of reasonable medical 

certainty and must be supported by medical reasoning explaining the nature of the relationship of 

the diagnosed condition and the specific employment factors or employment injury.18

ANALYSIS -- ISSUE 2 

Appellant claimed that she sustained reflex sympathetic dystrophy syndrome/complex 

regional pain syndrome of the right upper extremity, consequential to carpal tunnel syndrome 

and enesopathies. OWCP denied the claim, finding that the medical evidence did not contain 

sufficient rationale supporting a causal relationship between work factors and the claimed 

condition. 

In support of her claim, appellant provided reports dated from April to July 2013 from 

Dr. Shanbhag, an attending Board-certified physiatrist, who diagnosed complex regional pain 

syndrome of the right upper extremity. However, he did not address whether the accepted 

conditions or other work factors caused the claimed condition. Therefore, Dr. Shanbhag’s 

opinion is insufficient to meet appellant’s burden of proof.19 

Dr. Malloy, an attending Board-certified family practitioner, initially diagnosed brachial 

neuritis on January 22, 2013, then changed her diagnosis to reflex sympathetic dystrophy from 

 17 Clement Jay After Buffalo, id. 

18 Charles W. Downey, 54 ECAB 421 (2003). 

19 Deborah L. Beatty, 54 ECAB 340 (2003). 
8

August 16, 2013 through September 8, 2014. The equivocal aspect of this opinion diminishes its 

probative quality.20 

Dr. Wong, an attending neurologist, opined on January 6, 2015 that complex regional 

pain syndrome was the “most likely cause” of appellant’s right arm pain and paresthesias. He 

opined on July 11, 2015 that repetitive upper extremity motions at work caused complex regional 

pain syndrome. Dr. Wong’s report contains a preprinted paragraph attributing the claimed 

condition to work factors. However, he did not offer an independent explanation supporting 

causal relationship. In the absence of such rationale, Dr. Wong’s report is insufficient to meet 

appellant’s burden of proof.21 

The Board finds that appellant has not submitted sufficient rationalized medical evidence 

supporting causal relationship between the claimed complex regional pain syndrome/reflex 

sympathetic dystrophy and the accepted bilateral carpal tunnel syndrome or upper extremity 

enesopathies. OWCP’s December 3, 2015 decision denying the claim is therefore proper under 

the law and facts of this case. 

On appeal, counsel asserts that OWCP’s December 3, 2015 decision was not rationalized 

and did not explain how the decision was reached. He contends that it appears that OWCP did 

not consider any evidence appellant submitted. As set forth above, the Board found that 

appellant failed to submit sufficient rationalized medical evidence to establish a causal 

relationship between the claimed complex regional pain syndrome and the accepted conditions. 

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 has not met her burden of proof to establish a recurrence 

of disability from March 25 to April 10, 2013 due to accepted right upper extremity conditions. 

The Board further finds that she has not met her burden of proof to establish reflex sympathetic 

dystrophy syndrome or complex regional pain syndrome of the right upper extremity, 

consequential to accepted upper extremity conditions. 

 20 D.D., 57 ECAB 734 (2006). 

21 Supra note 19. 
9

ORDER 

IT IS HEREBY ORDERED THAT the decision of the Office of Workers’ 

Compensation Programs dated December 3, 2015 is affirmed. 

Issued: July 5, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board