United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

E.C., Appellant 

and 

DEPARTMENT OF HOMELAND SECURITY, 

IMMIGRATION & CUSTOMS 

ENFORCEMENT, Dallas, TX, Employer 

__________________________________________ 

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Docket No. 16-0413 

Issued: June 20, 2016 

Appearances: Case Submitted on the Record

Jesse Terrell, Esq., for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

COLLEEN DUFFY KIKO, Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On January 4, 2016 appellant, through counsel, filed a timely appeal from an August 17, 

2015 decision of the Office of Workers’ Compensation Programs (OWCP).1

 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 claim. 

ISSUE 

The issue is whether appellant has met her burden of proof to establish a recurrence of 

medical condition on or after March 13, 2014 causally related to her accepted October 13, 2011 

employment injury. 

 1

 The Board notes that appellant submitted additional evidence after OWCP rendered its August 17, 2015 

decision. The Board’s jurisdiction is limited to reviewing the evidence that was before OWCP at the time of its final 

decision and, therefore, this additional evidence cannot be considered on appeal. 20 C.F.R. § 510.2(c)(1); Dennis E. 

Maddy, 47 ECAB 259 (1995); James C. Campbell, 5 ECAB 35, 36 n.2 (1952). 

2

 5 U.S.C. § 8101 et seq.
2

FACTUAL HISTORY 

On October 13, 2011 appellant, then a 51-year-old legal assistant, filed a traumatic injury 

claim (Form CA-1) alleging that on that same date she sustained a left hand injury when a file 

cabinet began to fall and she caught it with her left hand. She did not stop work. 

Following the work incident, appellant sought treatment with Dr. J. Jason Toth, Boardcertified in emergency medicine. On October 24, 2011 Dr. Toth reported that a file cabinet had 

fallen on appellant at work striking her left shoulder, arm, elbow, and wrist. He diagnosed strain 

of left elbow and forearm and strain of left shoulder and upper arm, and noted appellant’s work 

restrictions. In a November 18, 2011 medical report, Dr. Toth released appellant to full duty 

without restrictions. On December 7, 2011 Dr. Toth updated work restrictions to no pushing, 

pulling, or lifting over 25 pounds. 

By decision dated January 26, 2012, OWCP accepted the claim for sprains of the left 

shoulder, upper arm, elbow, and forearm. 

On February 6, 2012 appellant was evaluated by her treating physician, Dr. George W. 

Balfour, a Board-certified orthopedic surgeon. Dr. Balfour related appellant’s history of injury, 

and noted complaints of continued pain in the left shoulder girdle down to the hand. Dr. Balfour 

noted symptoms in the median nerve distribution, at the dorsum of the hand, to the backs of the 

fingers on the left, and in and about the left shoulder. He diagnosed left shoulder sprain/strain 

and opined that appellant should continue working with modified duties limiting use of the left 

upper extremity. 

Appellant continued to seek treatment with Dr. Balfour, but from March 8, 2012 through 

June 26, 2014 she was working full-time work duties with no restrictions. 

In an April 25, 2013 evaluation, Dr. Balfour reported that appellant had been performing 

her customary work duties. He diagnosed left arm pain caused by her usual work activities. 

Dr. Balfour noted few positive physical examination findings, determined that appellant had 

reached a permanent and stationary status, and found that maximum medical improvement had 

been reached. As such, he determined that appellant had no ratable impairment and vocational 

rehabilitation was not needed. 

In medical reports dated March 13 to June 26, 2014, Dr. Balfour reiterated that appellant 

was working full duty, but noted that appellant complained of pain in the left elbow and 

shoulder. Impingement tests at the left shoulder, external/internal rotation, and abduction caused 

weak positive, minimal impingement pain/signs. Dr. Balfour diagnosed left shoulder 

impingement syndrome and requested physical therapy for her left elbow and shoulder, but noted 

that appellant could continue with her regular work with no restrictions. 

By letter dated March 11, 2015, appellant requested that OWCP authorize continuing 

treatment and physical therapy for her accepted conditions. 

By letter dated March 23, 2015, OWCP informed appellant that Dr. Balfour’s April 25, 

2013 report did not establish that additional medical treatment for the accepted injury was 

necessary as he had earlier found her condition to be permanent and stationary. It informed her 
3

that to be entitled to additional medical treatment for her work injury after being released from 

care, or after not receiving care for a significant period of time, she must provide medical 

evidence to support that her need for treatment was due to a worsening of the accepted workrelated condition(s) without an intervening cause. An intervening cause would include new 

exposure to work factors, a new work injury, or an illness which arose since the original injury or 

work exposure. OWCP further informed her that if a new traumatic work injury occurred or new 

work factors were responsible for a new injury, a new claim would need to be created, even if the 

new incident or exposure involved the same part of the body as previously affected. 

By letter dated April 13, 2015, appellant reiterated her request for continued therapy due 

to her constant pain. She noted that her physician’s March 13, 2014 report requested 

authorization for further therapy and she resubmitted his report in support of her claim. 

By letter dated April 29, 2015, OWCP informed appellant that the evidence of record was 

insufficient to support her recurrence claim. Appellant was provided with a questionnaire for 

completion, advised of the medical and factual evidence needed, and was afforded 30 days to 

submit this evidence. She did not respond and no further evidence was submitted. 

By decision dated August 17, 2015, OWCP denied appellant’s claim for recurrence of the 

need for medical treatment because the medical evidence failed to establish that additional 

treatment was necessary for the accepted October 13, 2011 injuries. 

LEGAL PRECEDENT 

A recurrence of a medical condition is defined as a documented need for further medical 

treatment after release from treatment for the accepted condition or injury.3 Continuous 

treatment for the original condition or injury is not considered a recurrence of a medical 

treatment nor is an examination without treatment.4 As distinguished from a recurrence of 

disability, a recurrence of a medical condition does not involve an accompanying work 

stoppage.5 

It is the employee’s burden of proof to establish that the claimed recurrence is causally 

related to the original injury.6 Causal relationship is a medical issue that can generally be 

resolved only by rationalized medical opinion evidence.7 This requires furnishing medical 

evidence from a physician who, on the basis of a complete and accurate factual and medical 

history, concludes that the condition is causally related to the employment injury and who 

 3

 20 C.F.R. § 10.5(y). 

4 Id.

5 Id. at § 10.5(x); see also D.T., Docket No. 15-1114 (issued February 1, 2016). 

6 Id. at § 10.104. See also Mary A. Ceglia, 55 ECAB 626 (2004). 

7 See Jennifer Atkerson, 55 ECAB 317 (2004). 
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supports that conclusion with sound medical reasoning.8 Where no such rationale is present, 

medical evidence is of diminished probative value.9 

In order to establish that an alleged recurrence of medical condition was caused by the 

accepted injury, medical evidence of bridging symptoms between her present condition and the 

accepted injury must support the physician’s conclusion of a causal relationship.10 

ANALYSIS 

OWCP accepted appellant’s claim for sprain of left elbow, forearm, shoulder, and upper 

arm. Appellant did not stop work and was provided work restrictions by Dr. Toth beginning on 

October 24, 2011. She returned to full-duty work without restrictions on March 8, 2012 based 

on the reports of Dr. Balfour. The issue is whether appellant has established a recurrence of a 

medical condition on or after March 13, 2014 causally related to her accepted October 13, 2011 

injury. 

By letter dated April 13, 2015, appellant requested authorization for continued treatment 

and therapy due to constant pain in her left shoulder which she alleged stemmed from the 

accepted October 13, 2011 injury. In support of her claim, she submitted Dr. Balfour’s 

March 13, 2014 medical report requesting additional physical therapy due to a newly diagnosed 

left shoulder impingement syndrome. However, appellant failed to provide a sufficiently 

rationalized medical opinion explaining a causal relationship between her need for medical 

treatment and her October 13, 2011 employment injury. The Board finds that she has not met 

her burden of proof to establish her claim. 

In work status notes dated March 8, 2012 and continuing, Dr. Balfour released appellant 

to full-duty work without restrictions. In his April 25, 2013 report, Dr. Balfour noted few 

positive physical examination findings, diagnosed left arm pain caused by work activities, and 

opined that appellant had reached a permanent and stationary status. In subsequent reports dated 

March 13 to June 26, 2014, Dr. Balfour diagnosed left shoulder impingement syndrome and 

requested physical therapy for continued treatment. 

The Board finds that Dr. Balfour has failed to explain how the newly diagnosed condition 

of left shoulder impingement syndrome was causally related to the accepted sprain of the upper 

extremity. The Board notes that an increase in pain alone does not constitute objective evidence 

of a diagnosed condition.11 Moreover, the diagnosis of left shoulder impingement syndrome has 

not been accepted as a compensable condition. The Board notes that Dr. Balfour’s opinion does 

not support a spontaneous recurrence of a left upper extremity sprain.12 

 8 Dennis E. Twardzik, 34 ECAB 536 (1983); Max Grossman, 8 ECAB 508 (1956). 

9 Michael Stockert, 39 ECAB 1186, 1187-88 (1988); see Ronald C. Hand, 49 ECAB 113 (1957). 

10 Mary A. Ceglia, supra note 6. 

11 See Federal (FECA) Procedure Manual, Part 2 -- Claims, Recurrences, Chapter 2.1500.6.a(2) (June 2013). 

12 L.G., Docket No. 11-142 (issued August 12, 2011). 
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With respect to the accepted work-related injuries of sprain of left elbow, forearm, 

shoulder, and upper arm, Dr. Balfour determined that the conditions had resolved. His April 25, 

2013 report diagnosed left arm pain which he opined was caused by appellant’s usual and 

customary work activities. It is unclear if Dr. Balfour is attributing appellant’s medical 

conditions to an occupational injury produced by her work environment over a period longer 

than a single workday or due to residuals of her October 13, 2011 employment injury.13 This 

statement does not provide support for a recurrence of her accepted medical condition. 

Appellant has failed to submit any medical reports from a physician who, on the basis of 

a complete and accurate factual and medical history, concluded that she continued to require 

medical treatment due to the accepted work injury. As appellant has not submitted any medical 

evidence showing that she sustained a recurrence of medical condition due to her accepted 

employment injury, the Board finds that she has not met her burden of proof.14

Appellant may submit new evidence or argument with a written request for 

reconsideration to the 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 recurrence 

of medical condition on or after March 13, 2014, causally related to her accepted October 13, 

2011 employment injuries. 

 13 A traumatic injury means a condition of the body caused by a specific event or incident or series of events or 

incidents, within a single workday or shift. 20 C.F.R. § 10.5(ee). An occupational disease is defined as a condition 

produced by the work environment over a period longer than a single workday or shift. 20 C.F.R. § 10.5(q). 

14 L.L., Docket No. 13-2146 (issued March 12, 2014). See also William A. Archer, 55 ECAB 674, 679 (2004). 
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ORDER 

IT IS HEREBY ORDERED THAT the August 17, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: June 20, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board