United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

S.M., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

West Sacramento, CA, Employer 

___________________________________________

) 

) 

) 

) 

) 

) 

) 

) 

Docket No. 16-0593 

Issued: February 24, 2017 

Appearances: Case Submitted on the Record 

Alan J. Shapiro, Esq., for the appellant1

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On February 9, 2016 appellant, through counsel, filed a timely appeal from a 

December 15, 2015 merit decision of the Office of Workers’ Compensation Programs (OWCP). 

Pursuant to the Federal Employees’ Compensation Act2

 (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 his burden of proof to establish a traumatic injury 

causally related to a September 2, 2014 employment incident. 

 1

 In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for 

legal or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. 

§ 501.9(e). No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An 

attorney or representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject 

to fine or imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a 

representative, prior to approval by the Board, may be reported to appropriate authorities for investigation. 

2

 5 U.S.C. § 8101 et seq.
2

FACTUAL HISTORY 

On October 1, 2014 appellant, then a 51-year-old sales and distribution associate, filed a 

traumatic injury claim (Form CA-1) alleging that on September 2, 2014 he sustained an injury to 

his right shoulder while processing undeliverable parcels. The employing establishment 

controverted the claim and checked a box marked “no” in response to whether he was injured in 

the performance of duty. The employing establishment indicated that appellant did not report the 

injury and faxed the claim forms over 30 days later. Appellant stopped work on 

September 2, 2014. 

In an October 3, 2014 statement, appellant indicated that he got off the telephone with his 

human resources office, who advised him to notify them of the injury. He indicated that on 

September 2, 2014 he was helping to scan and move parcels. When he went to retrieve a parcel 

from the hamper, he heard a popping sound in his right shoulder. Appellant explained that he 

waited to provide notice of his injury as he had hoped that it would get better. He further noted 

that, when he was working at the plant, his belly button popped and was sticking out as he had 

sustained an umbilical hernia. 

In an October 3, 2014 report, Dr. Theodore Muller, Board-certified in emergency 

medicine, noted that appellant was moving and lifting boxes and was reaching to retrieve a 

package from a plastic hamper when he felt his right shoulder pop. He advised that later that 

evening appellant began to experience pain in the right shoulder. Dr. Muller diagnosed bilateral 

shoulder strain. 

October 3, 2014 hospital discharge instructions from Dr. Gurmail Brar, Board-certified in 

family medicine, revealed that appellant had shoulder pain and overuse syndrome. 

In a January 7, 2015 letter, OWCP advised appellant that additional factual and medical 

evidence was needed in support of his claim. It asked that he further explain how the injury 

occurred and why he had delayed informing the employing establishment of his claimed injury. 

OWCP also explained that a physician’s opinion explaining how the reported work incident 

caused or contributed to appellant’s condition was crucial to his claim. 

In December 19, 2014 reports, Dr. Deven Merchant, Board-certified in emergency 

medicine, noted that appellant’s chief complaint was an injury to the right shoulder and the 

“injury happened about 4 months ago.” He noted that appellant had a twisting injury that 

occurred at work on September 2, 2014. Dr. Merchant examined him and found upper back 

pain, joint pain involving the right shoulder and left shoulder, and neck pain. He found no 

tenderness, swelling or deformity and no limitation of motion in the right shoulder or decreased 

range of motion at the shoulders. Dr. Merchant diagnosed sprained right shoulder. 

OWCP received copies of previously submitted reports including a copy of the 

October 3, 2014 report from Dr. Muller, nursing notes, physician assistant’s notes, and a 

medication form. 

In a January 19, 2015 statement, appellant explained that he tried to file the claim forms 

by faxing them to his supervisor and his postmaster, but he never received a response. He 
3

explained that he was concerned that he would be subjected to harassment, discrimination, or 

intimidation from his supervisor if he filed a claim. Appellant filed the forms and his supervisors 

resisted assisting him. He described his injury when he felt a pop in his right shoulder and the 

excruciating pain he felt afterwards on the following morning. Appellant denied any history of 

prior injuries. He also indicated that on September 3, 2014 he called in his claim via an 

automated system. Appellant also provided a copy of an October 3, 2014 e-mail to his 

supervisors advising them that he injured his right shoulder at work. He also provided a 

December 19, 2014 statement in which he again described his injury and explained that he 

immediately got up and notified the employing establishment of the work-related injury through 

an automated system. Appellant explained that he continued to call-in for a month using his sick 

and annual leave trying to rest his shoulder in hope that the injury would heal. He noted that 

after four weeks, it had not improved, so he visited the emergency room and then faxed a CA-1 

claim form to his supervisor on October 1, 2014. 

In a December 7, 2014 report, Dr. Muller noted appellant’s history of injury at work and 

diagnosed bilateral shoulder strain. He checked a box marked “yes” in response to whether his 

diagnosis was consistent with the history of injury and treatment. 

OWCP also received status reports dated January 8 and 16, 2015 from a nurse and reports 

from a physician assistant and copies of previous reports. 

A January 8, 2015 cervical spine x-ray read by Dr. Robert Wankmuller, Jr., a Boardcertified diagnostic radiologist, revealed mild C4-C5 and moderate-to-severe C5-C6 

degenerative disc disease with endplate spurring and a nonacute fracture of the base of the 

odontoid. A January 8, 2015 x-ray of both shoulders read by Dr. Wankmuller, Jr. revealed mild 

right acromioclavicular (AC) joint arthritis and negative bilateral shoulders. 

In a January 8, 2015 treatment note, Dr. Rajpreet Dhesi, Board-certified in physical 

medicine and rehabilitation, diagnosed right shoulder strain and recommended physical therapy. 

In a January 9, 2015 attending physician’s report (Form CA-20), he checked the box marked 

“yes” in response to whether he believed the condition was caused or aggravated by an 

employment activity. Dr. Dhesi advised that appellant could return to light-duty work on that 

date with restrictions including no work over shoulder level, limited pulling and pushing to five 

pounds, and no safety sensitive job duties. In a January 16, 2015 treatment note, he diagnosed: 

sprain of the shoulder and arm; sprain of the neck; radiculitis cervical and brachial not otherwise 

specified; and carpal tunnel syndrome. Dr. Muller recommended a return to modified duty on 

January 16, 2015 and opined that, based upon the information he had received, the problem was 

work related. 

On February 5, 2015 OWCP received an additional statement from appellant describing 

his activities at work on September 2, 2014. 

By decision dated March 3, 2015, OWCP denied appellant’s claim, finding that he had 

not established an injury as alleged. It indicated that it was difficult to understand that if 

appellant actually injured his right shoulder and felt a “pop” after a heavy parcel slipped out of 

his hands then, why would he not immediately report this to his supervisor or to a physician as a 

work-related injury. OWCP noted that the only explanation he had provided was his fear of 
4

harassment and retaliation, along with his hope that he would heal with rest so he would not have 

to file a claim. It found that appellant failed to submit sufficient evidence to support that a right 

shoulder injury occurred at the time, place, and in the manner alleged. OWCP also found that 

the medical evidence of record did not contain a diagnosis in connection with the injury or events 

alleged.

On March 12, 2015 counsel requested a telephonic hearing, which was held before an 

OWCP hearing representative on October 5, 2015. 

OWCP also received a December 8, 2014 response to appellant’s claim for 

discrimination, a March 31, 2015 Equal Employment Opportunity (EEO) report and copies of 

prior submitted reports. 

In a letter dated November 4, 2015, I.W., a human resources specialist, confirmed that 

there was no automated system to report accidents or injuries. She explained that, in order to 

report a work injury, the employee must “personally tell the supervisor/manager verbally or in 

writing (CA-1 or CA-2) that an injury occurred.” 

By decision dated December 15, 2015, an OWCP hearing representative affirmed the 

March 3, 2015 decision. He found that it was accepted that appellant was required to perform 

lifting of parcels in the performance of duty. However, appellant failed to provide sufficient 

medical evidence which addressed the causal relationship of the injury and diagnosis provided of 

sprain right acromioclavicular by medical rationale to the accepted employment trauma of 

September 2, 2014. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA3

 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,4 and that an injury was sustained in the performance 

of duty.5

 These are the essential elements of each and every compensation claim, regardless of 

whether the claim is predicated upon a traumatic injury or an occupational disease.6

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 actually experienced the employment incident at 

 3 Id. 

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

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

6 Delores C. Ellyett, 41 ECAB 992 (1990). 
5

the time, place, and in the manner alleged.7

 In some traumatic injury cases, this component can 

be established by an employee’s uncontroverted statement on the Form CA-1.8

 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 

OWCP accepted that on September 2, 2014 appellant was required to lift parcels in the 

performance of duty. The Board finds that the first component of fact of injury is established as 

the incident occurred as alleged on September 2, 2014. 

However, the Board finds that the medical evidence of record 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 

employment incident on September 2, 2014 caused or aggravated an injury.11

Appellant submitted to OWCP an October 3, 2014 report from Dr. Muller, noting that 

appellant was moving and lifting boxes and was reaching to pick up a package from a plastic 

hamper when he felt his right shoulder pop. Dr. Muller advised that, later that evening, he began 

to experience pain in the right shoulder. He diagnosed bilateral shoulder strain. However, 

Dr. Muller offered no opinion on causal relationship. Medical evidence that does not offer any 

opinion regarding the cause of an employee’s condition is of limited probative value on the issue 

of causal relationship.12

In a December 7, 2014 report, Dr. Muller noted appellant’s history of injury at work and 

diagnosed bilateral shoulder strain. He checked a box marked “yes” in response to whether his 

diagnosis was consistent with the history of injury and treatment. However, the Board has held 

 7 Julie B. Hawkins, 38 ECAB 393, 396 (1987); see Federal (FECA) Procedure Manual, Part 2 -- Claims, Fact of 

Injury, Chapter 2.803.3.b (August 2012). 

8 John J. Carlone, 41 ECAB 354 (1989). 

9 Id.

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

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 S.E., Docket No. 08-2214 (issued May 6, 2009). 
6

that checking of a box “yes” in a form report, without additional explanation or rationale, is 

insufficient to establish causal relationship.13 

In December 19, 2014 reports, Dr. Merchant noted that appellant’s chief complaint was 

an injury to the right shoulder and that the “injury happened about 4 months ago.” He noted that 

appellant had a twisting injury that occurred at work on September 2, 2014. Dr. Merchant 

examined him and found upper back pain, joint pain involving both shoulders, and neck pain. 

He diagnosed a sprained right shoulder. While he noted that the injury occurred at work on 

September 2, 2014, Dr. Merchant did not offer a rationalized opinion on causal relationship. 

Therefore, this report is of limited probative value.14

In a January 9, 2015 attending physician’s report, Dr. Dhesi checked a box marked “yes” 

in response to whether he believed appellant’s medical condition was caused or aggravated by an 

employment activity. He also provided a return to light-duty work with restrictions. However, 

as found above, checking of a box “yes” in a form report, without additional explanation or 

rationale, is insufficient to establish causal relationship.15

A January 8, 2015 cervical spine x-ray read by Dr. Wankmuller, Jr. revealed mild C4-C5 

and moderate-to-severe C5-C6 degenerative disc disease with endplate spurring and a nonacute 

fracture of the base of the odontoid. In addition, a January 8, 2015 x-ray of both shoulders 

revealed mild right AC joint arthritis and negative bilateral shoulders. However, these reports 

are insufficient to prove causal relationship because Dr. Wankmuller, Jr. did not offer any 

opinion as to whether the established work incident was sufficient to cause or aggravate the 

diagnosed medical conditions. Therefore, these reports have no probative value in establishing 

causal relationship.16 

The record contains nursing and physician assistant’s notes. However, registered nurses, 

licensed practical nurses, and physician assistants are not considered “physicians” as defined 

under FECA. Therefore, their opinions are of no probative value.17

Other medical records of evidence do not address causal relationship and are, therefore, 

of no probative value. 

Because the medical evidence of record fails to address how the September 2, 2014 

employment incident caused or aggravated a right shoulder condition, appellant has failed to 

meet his burden of proof. 

 13 Calvin E. King, 51 ECAB 394 (2000); Linda Thompson, 51 ECAB 694 (2000). 

14 See supra note 11. 

15 See supra note 12. 

16 See Michael E. Smith, 50 ECAB 313 (1999). 

17 Roy L. Humphrey, 57 ECAB 238 (2005). 
7

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 his burden of proof to establish that he 

sustained a traumatic injury causally related to a September 2, 2014 employment incident. 

ORDER 

IT IS HEREBY ORDERED THAT the December 15, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: February 24, 2017 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board