United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

S.C., Appellant 

and 

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS ADMINISTRATION MEDICAL 

CENTER, Northport, NY, Employer 

__________________________________________ 

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Docket No. 17-0412 

Issued: June 15, 2017 

Appearances: Case Submitted on the Record

Thomas S. Harkins, Esq., for the appellant1

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On December 14, 2016 appellant, through counsel, filed a timely appeal from a July 13, 

2016 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 to consider the merits of the case. 

ISSUE 

The issue is whether appellant has met his burden of proof to establish a traumatic injury 

causally related to a May 8, 2015 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

Counsel contends on appeal that appellant has established that the employment incident 

occurred as alleged. 

FACTUAL HISTORY 

On May 12, 2015 appellant, then a 57-year-old food service worker, filed a traumatic 

injury claim (Form CA-1) alleging that he sustained a lower back strain and tightness in his legs 

and ankles after lifting a large number of milk crates on May 8, 2015. 

The employing establishment provided appellant with an authorization for examination or 

treatment (Form CA-16) and indicated that on May 8, 2015 appellant was lifting milk cartons 

within the walk-in refrigerator and injured his shoulder. It indicated that the milk cartons 

weighed approximately 50 pounds. On the reverse side of the claim form, appellant’s physician, 

Dr. Amir Herman, an osteopath, indicated that appellant was lifting heavy milk cartons, 

weighing 50 pounds and experienced pain in his back radiation down his left leg. He reviewed 

diagnostic testing and found degenerative disc disease of the lumbosacral spine, and sciatica. 

Dr. Herman indicated by checking a box marked “yes” that appellant’s condition was caused or 

aggravated by work activity. He also noted that appellant had no pain prior to lifting. 

In a letter dated June 5, 2015, OWCP noted that when appellant’s claim was received, it 

appeared to be a minor injury that resulted in no lost time from work. Based on this, payment of 

a limited amount of medical expenses was approved, but the merits of the claim were not 

considered. OWCP reopened appellant’s claim because he had not returned to full-duty work. It 

requested additional factual and medical evidence in support of appellant’s claim and afforded 

appellant 30 days to respond. 

Dr. Herman completed a note on May 13, 2015 and reported that appellant was lifting 

heavy objects at work and developed low back pain radiating down his right leg. X-rays 

demonstrated severe degenerative disc disease at L4-5 and L5-S1. Dr. Herman diagnosed 

lumbago with sciatica, and muscle spasm. He provided work restrictions. Dr. Herman 

completed a form report on May 26, 2015 and diagnosed sciatica, backache, and muscle spasm. 

On June 11, 2015 he found that appellant had significant pain in his legs and paresthesias 

bilaterally from his buttocks to his calves. Dr. Herman again diagnosed lumbago with sciatica, 

muscle spasm, and lower extremity paresthesias. 

Appellant provided a narrative statement on June 12, 2015 and reported that on May 8, 

2015 he was working the walk-in refrigerator unwrapping milk. He indicated that the employing 

establishment received an unusually large milk order and that he had to rotate the milk that was 

already in the refrigerator. This task involved a lot of bending, stooping, and twisting. Appellant 

reported that the milk cartons weighed more than 40 pounds each and he moved between 35 and 

40 cartons. Upon leaving the refrigerator, appellant’s supervisor noted that he was limping and 

directed him to medical treatment. Appellant listed his symptoms as tightness in his back, pains 

down his leg, limping, and numbness in his leg. 

In a decision dated July 8, 2015, OWCP denied appellant’s traumatic injury claim finding 

that he had not submitted sufficient medical evidence to establish causal relationship between his 

diagnosed conditions of lumbar strain and degenerative disc disease and his accepted 

employment incident. On July 21, 2015 it modified the July 8, 2015 decision finding that 
3

appellant had not submitted medical evidence sufficient to explain how the accepted employment 

incident caused or affected his condition.3

In a note dated July 1, 2015, Dr. Herman reported that appellant’s pain increased when he 

returned to work. He noted that appellant underwent a magnetic resonance imaging (MRI) scan 

on June 19, 2915 which demonstrated degenerative disc disease, and disc herniation. 

Dr. Joseph T. Sanelli, an osteopath, examined appellant on July 6, 2015 due to reports of 

constant lumbar pain and stiffness with radiation into the bilateral lower extremities. He 

attributed these conditions to a work-related injury on May 8, 2015 when appellant was moving 

40 crates of milk weighing 45 pounds each. 

On July 9, 2015 Dr. Herman again diagnosed lumbago with sciatica, spasm of muscle, 

and herniated lumbar disc. In a note dated July 16, 2015, he disagreed with OWCP’s decision 

and noted that appellant did not have any pain or discomfort prior to his workplace injury, but 

that since the injury appellant has had pain in his buttocks and leg. Dr. Herman opined that 

causality had been established. He noted that, although appellant had preexisting evidence of 

degenerative disc disease of the lumbar spine, appellant was not in any pain at the time of the 

workplace incident and that subsequent to the incident appellant had unrelenting pain. 

Dr. Herman completed a note on August 4, 2015 and again diagnosed lumbago with 

sciatica, muscle spasm, and herniated lumbar disc. On September 2, 2015 Dr. Sanelli examined 

appellant and diagnosed lumbar disc displacement with myelopathy, discogenic syndrome, and 

lumbar myofascial. He reviewed appellant’s June 19, 2015 MRI scan and found multilevel 

degenerative changes with stenosis and a small herniated disc at L4-5. Dr. Sanelli opined that 

appellant was temporarily totally disabled. In a note dated October 13, 2015, he diagnosed 

degenerative disc disease of the lumbar spine, lumbar disc displacement, lumbar discogenic 

syndrome, lumbar facet syndrome, and sciatica. 

Dr. Herman completed a narrative report on November 10, 2015 and described 

appellant’s history of lifting heavy objects at work on May 8, 2015. He noted, “[Appellant] 

developed low back pain and pain radiating down his right leg upon lifting the objects.” 

Dr. Herman again reported that appellant was not in any pain or discomfort prior to lifting at 

work, and since that injury was having pain in the buttock and leg. He opined, “I believe that the 

patient’s causality HAS indeed been established as although he had preexisting evidence of 

[degenerative disc disease] of the [lumbosacral] spine, he was not in any pain at the time of the 

workplace incident, and subsequent to the incident he has had nonrelenting pain.” (Emphasis in 

the original.) 

In a report dated October 22, 2015, Dr. Sanelli indicated that appellant reported a workrelated injury on May 8, 2015 when he sustained the immediate onset of back pain after moving 

40 crates of milk weighing 45 pounds each. He reviewed appellant’s June 19, 2015 MRI scan 

and found multilevel degenerative changes, disc bulges, and stenosis as well as a herniated disc 

at L4-5. Dr. Sanelli concluded, “It is my medical opinion that the injuries and disability, as so 

 3

 Appellant requested a telephonic hearing on July 15, 2015 from OWCP’s Branch of Hearings and Review. 

Counsel withdrew this request on August 11, 2015. In a letter dated August 13, 2015, OWCP accepted counsel’s 

request for withdrawal. 
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noted in this narrative report are causally related to the [w]orkers’ [c]ompensation injury of 

May 8, 2015 that occurred while in the course of his federal employment....” 

Counsel requested reconsideration on December 30, 2015 and April 15, 2016. On 

February 22, 2016 Dr. Sanelli indicated that appellant reported back pain. In a note dated 

March 25, 2016, Dr. Thomas J. Dowling, a Board-certified orthopedic surgeon, noted that 

appellant had returned to full duty. On May 25, 2015 Dr. Sanelli examined appellant and 

diagnosed lumbar disc displacement, lumbar discogenic syndrome, and lumbosacral 

degenerative disc disease. 

By decision dated July 13, 2016, OWCP reopened appellant’s claim for consideration of 

the merits and found that appellant had not established a causal relationship between his accepted 

employment incident and his diagnosed conditions and lumbar strain and degenerative disc 

disease. 

LEGAL PRECEDENT 

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

essential elements of his or her claim by the weight of the reliable, probative and substantial 

evidence, 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, that an injury was sustained in the performance of duty as alleged, and that any disability 

or specific condition for which compensation is claimed is causally related to the employment 

injury.4

 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.5

OWCP defines a traumatic injury as, “[A] condition of the body caused by a specific 

event or incident, or series of events or incidents, within a single workday or shift. Such 

condition must be caused by external force, including stress or strain which is identifiable as to 

time and place of occurrence and member or function of the body affected.”6

 To determine 

whether a federal employee has sustained a traumatic injury in the performance of duty, it must 

first be determined whether “fact of injury” has been established. First the employee must 

submit sufficient evidence to establish that he actually experienced the employment incident at 

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

 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.8

A medical report is of limited probative value on a given medical question if it is 

unsupported by medical rationale.9 Medical rationale includes a physician’s detailed opinion on 

 4 Id.; Elaine Pendleton, 41 ECAB 1143 (1989). 

5 Victor J. Woodhams, 41 ECAB 345 (1989). 

6

 20 C.F.R. § 10.5(ee). 

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

8 J.Z., 58 ECAB 529 (2007). 

9 T.F., 58 ECAB 128 (2006). 
5

the issue of whether there is causal relationship between the claimant’s diagnosed condition and 

the implicated employment activity. The opinion of the physician must be based on a complete 

factual and medical background of the claim, 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 specific employment activity or factors identified by the claimant.10

ANALYSIS 

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

injury causally related to a May 8, 2015 employment incident. 

Appellant submitted consistent factual information that he lifted multiple milk crates in 

the performance of his job duties on May 8, 2015. He provided medical evidence diagnosing a 

variety of conditions including degenerative disc disease of the lumbosacral spine, and sciatica. 

Drs. Herman and Sanelli opined that appellant’s diagnosed conditions were caused or aggravated 

by his lifting on May 8, 2015. In his October 22, 2015 report, Dr. Sanelli provided a history of 

injury and opined that appellant’s diagnosed back conditions occurred while in the course of his 

federal employment. Dr. Herman repeatedly opined that appellant’s diagnosed back conditions 

were caused by his lifting. 

The Board, however, finds that both Dr. Herman’s and Dr. Sanelli’s reports lack the 

necessary medical reasoning to meet appellant’s burden of proof. The Board has held that the 

mere manifestation of a condition during a period of employment does not raise an inference that 

there is a causal relationship between the condition and the employment. Neither the fact that 

the condition became apparent during a period of employment, nor the belief that the 

employment caused or aggravated a condition is sufficient to establish causal relationship.11 

Therefore, Dr. Herman’s opinion regarding the temporal relationship between appellant’s back 

conditions and his employment incident is insufficiently reasoned to meet appellant’s burden of 

proof. Dr. Sanelli also failed to provide rationale explaining how the May 8, 2015 work incident 

caused or aggravated a diagnosed medical condition.12

Other medical evidence provided by appellant is of limited probative value as it does not 

specifically address whether the May 8, 2015 work incident caused or aggravated any particular 

medical condition.13

 Without a medical report based on a complete factual history, a clear diagnosis, and an 

opinion supported by medical reasoning explaining how lifting on May 8, 2015 resulted in the 

 10 A.D., 58 ECAB 149 (2006). 

11 Supra note 3. 

12 See supra note 10. 

13 See Jaja K. Asaramo, 55 ECAB 200 (2004) (medical evidence that does not offer any opinion regarding the 

cause of an employee’s condition is of diminished probative value on the issue of causal relationship). 
6

diagnosed conditions, appellant has not meet his burden of proof to establish a traumatic injury 

in the performance of duty.14

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 his burden of proof to establish a traumatic 

injury causally related to a May 8, 2015 employment incident. 

ORDER 

IT IS HEREBY ORDERED THAT the July 13, 2016 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: June 15, 2017 

Washington, DC 

 

 Patricia H. Fitzgerald, Deputy 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 

 14 The Board notes that where an employing establishment properly executes a Form CA-16 which authorizes 

medical treatment as a result of an employee’s claim for an employment-related injury, the Form CA-16 creates a 

contractual obligation, which does not involve the employee directly, to pay for the cost of the examination or 

treatment regardless of the action taken on the claim. See Tracy P. Spillane, 54 ECAB 608 (2003). The period for 

which treatment is authorized by a Form CA-16 is limited to 60 days from the date of issuance, unless OWCP 

terminates the authorization sooner. See 20 C.F.R. § 10.300(c). The record is silent as to whether OWCP paid for 

the cost of appellant’s examination or treatment for the period noted on the CA-16 form issued in this case.