United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

L.G., Appellant

and

DEPARTMENT OF THE TREASURY, OFFICE 

OF THE SECRETARY, Washington, DC, 

Employer

__________________________________________

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Docket No. 18-0321

Issued: October 25, 2018

Appearances: Case Submitted on the Record

Steven E. Brown, 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 November 30, 2017 appellant, through counsel, filed a timely appeal from a June 6, 

2017 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.

 

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

ISSUE

The issue is whether appellant has established that the acceptance of the claim should be 

expanded to include the additional conditions of concussion; postconcussion syndrome; posttraumatic migraine; occipital headaches and fatigue; occipital neuritis; neck sprain; cervical strain 

syndrome with cervicalgia; saccadic eye movement deficiency and vestibular dysfunction; 

cervical, lumbar, and brachial radiculopathy symptoms; ulnar neuropathy; and carpal tunnel 

syndrome.

FACTUAL HISTORY

This case has previously been before the Board.3 The facts and circumstances outlined in 

the Board’s prior decision are incorporated herein by reference. The relevant facts are as follows.

On October 21, 2013 appellant, then a 31-year-old economist, filed a traumatic injury claim 

(Form CA-1) alleging that, on August 16, 2013, she sustained injuries when she fell down stairs 

while entering the building where she worked.

By decision dated January 7, 2014, OWCP initially denied the claim, finding that appellant 

had not established that the claimed incident occurred as alleged. On February 4, 2015 it accepted 

her claim for knee sprain, bilateral ankle sprain, right tibia contusion, and lumbar sprain. 

In correspondence dated February 12, 2015, counsel requested that the acceptance of 

appellant’s claim be expanded to include the additional conditions of: myofascial pain syndrome; 

reflex sympathetic disorder (RSD) which affected his lower right and upper left extremities; a 

concussion; postconcussion syndrome; post-traumatic migraine; occipital headaches and fatigue;

occipital neuritis; neck sprain; cervical strain syndrome with cervicalgia; saccadic eye movement 

deficiency and vestibular dysfunction; cervical, lumbar, and brachial radiculopathy symptoms; 

ulnar neuropathy; and carpal tunnel syndrome. 

Medical evidence subsequently submitted included an October 19, 2014 report in which

Dr. Henry M. Friedman, an optometrist, noted seeing appellant for a vision and eye health 

examination due to dizziness with eye movement, headache and eyestrain associated with reading, 

and blurred distance vision, all of which began with a concussion injury on August 16, 2013. 

Following eye examination, Dr. Friedman had advised that appellant’s saccadic eye movements 

showed occasional undershoots and her binocular coordination was grossly abnormal, and noted 

that testing caused pain. He recommended a program of vision therapy to improve spatial 

localizing skills, binocular posturing, and visual-vestibular integration in an aid to eliminate 

dizziness, headache, and eyestrain. In a January 30, 2015 report, Dr. Friedman opined that 

appellant’s symptoms were atypical of most developmental or stress-induced visual problems and, 

therefore, it seemed logical that they were the result of brain injury. 

In follow-up reports dated May 27 to September 16, 2015, Dr. James Weiss, a Boardcertified orthopedic surgeon, noted appellant’s complaints of RSD in her hands and continued 

upper and lower back, right hip and thigh, and right knee symptoms, and had been seen by a 

 

3 Docket No. 17-1448 (issued December 19, 2017). 
3

neurosurgeon, had a sleep study done, was going to vision therapy, physical therapy, and had 

acupuncture treatments. He noted gradual improvement but opined that appellant continued to 

have significant residuals. 

In a report dated October 19, 2015, Dr. Kevin Crutchfield, a Board-certified neurologist, 

noted a current diagnosis of resolving post-traumatic occipital neuritis, with secondary headaches

associated with sensitivity to fluorescent lighting and computer screens. He advised that appellant 

continued to improve clinically, but had not reached maximum medical improvement and needed 

ongoing care for trauma-induced migraine headaches. Dr. Crutchfield noted that appellant’s visual 

disturbances and psychological issues further limited her ability to work, but that from a 

neurological standpoint she could have returned to part-time work in July 2015. He opined that, 

with a high degree of medical certainty or probability of at least 51 percent certainty, that 

August 16, 2013 employment injury clearly initiated appellant’s inability to function in her prior 

employed position. 

In October 2015 OWCP referred appellant to Dr. Donald Heitman, a Board-certified 

orthopedic surgeon, and Dr. Chandra Sharma, Board-certified in psychiatry and neurology, for 

second opinion evaluations. Each OWCP referral physician was to provide an opinion on as to 

appellant’s current condition, whether any diagnoses were a consequence of the August 16, 2013 

employment injury, whether the diagnosed RSD was caused by the employment injury, whether 

appellant continued to suffer residuals of the employment injury, and any period of total disability 

due to the work-related condition. 

In a report dated October 28, 2015, Dr. Heitman noted the history of injury and his review 

of the medical record including diagnostic testing. He described appellant’s complaints of low 

back bilateral knee, and bilateral ankle pain. Dr. Heitman found tenderness on examination of the 

right lumbosacral junction, right patellofemoral joint line, bilateral Achilles tendon, and right ankle 

joint with full range of motion of both knees and both ankles. He opined that appellant had a 

chronic lumbar strain with radiculopathy and advised that it could be connected to the work injury, 

but noted that diagnostic studies did not show any significant findings in the low back. 

Dr. Heitman found no current findings of knee or ankle pathology bilaterally and advised that he 

could not comment regarding RSD as that was out of his scope of expertise. He concluded that 

appellant had reached maximum medical improvement with respect to the accepted lumbar sprain, 

bilateral ankle sprain, and tibia contusion, that she required no further treatment, had no continuing 

residuals, and that there no periods of total disability for the accepted conditions.

In a report dated November 23, 2015, Dr. Sharma noted the history of injury, her review 

of the medical record, and appellant’s complaints of neck, upper and lower back, and right hip 

pain, and RSD involving both feet and the left arm, and vision problems. Following neurological 

examination, Dr. Sharma diagnosed multiple subjective pains and normal neurological 

examination. She opined that there were no neurological injuries sustained from the employment

injury, and that no further treatment was warranted. Dr. Sharma related that the subjective pains 

were related to the employment injury, but did not cause any neurological problems. Regarding 

RSD, she indicated that the sensory changesreported in appellant’sfeet and left hand were causally 

related, but again opined that these changes did not affect neurological function. Dr. Sharma

opined that appellant had no periods of total neurological disability and could work without 

restriction. 
4

Additional medical evidence included follow-up treatment notes dated January 11 and 

May 6, 2016 in which Dr. Weiss noted that appellant was doing better, but still had residual 

tenderness, noting that the right hip still caused discomfort. On May 12, 2016 Dr. Weiss indicated 

that he had reviewed medical records, including Dr. Heitman’s report and opined that he disagreed 

with the Dr. Heitman’s conclusions. He indicated that diagnostic studies would be negative for

RSD, and he found that appellant did have objective findings and needed continuing treatment. 

Dr. Weiss opined that, due to her employment injuries, appellant was totally disabled from 

August 16, 2013 to January 17, 2014, and partially disabled from January 17 to June 17, 2014. 

In a June 29, 2016 report, Dr. Crutchfield reiterated his opinion that the August 16, 2013 

fall had resulted in a stretch injury to her greater occipital nerve that caused post-traumatic occipital

neuritis, which had induced chronic, secondary headaches, and photosensitivity which made it 

impossible to perform office work. He opined that appellant’s signs and symptoms were caused 

by head and neck trauma she suffered when she fell on the stairs on August 16, 2013. 

In a September 28, 2016 report, Dr. Weiss noted that he had not seen appellant for 

approximately five months and she had improved significantly. He advised that she still had very 

slight residual myofascial symptoms and slight RSD. 

By letter dated March 15, 2017, counsel again requested that OWCP accept additional 

conditions of: myofascial pain syndrome; RSD, which affects both her lower right extremity and 

her upper left extremity; concussion; postconcussion syndrome; post-traumatic migraine; occipital 

headaches and fatigue; occipital neuritis; neck sprain; cervical strain syndrome with cervicalgia;

saccadic eye movement deficient and vestibular dysfunction; cervical, lumbar, and brachial 

radiculopathy symptoms; ulnar neuropathy; and carpal tunnel syndrome. He contended that all 

of these conditions were part of the original claim, but were never developed despite medical 

evidence of record from appellant’s treating physicians, and a decision had not been made on the 

February 12, 2015 request for expansion of the claim to include these same additional conditions. 

Counsel, therefore, requested that OWCP review the medical evidence of record and develop 

whether the additional conditions should be accepted.

By development letter dated May 4, 2017, OWCP advised appellant that it had reviewed

the medical evidence submitted and found it insufficient to expand acceptance of the claim to 

include the additional claimed conditions. It informed appellant of the type of evidence needed to 

establish expansion of the claim. This was to include a report from a treating physician who should 

provide a history of the injury including any similar problems which may have preexisted the 

conditions for which she was treated, current clinical findings and results of diagnostic testing, and 

any diagnosis or diagnoses resulting from the employment injury, along with a report of any 

condition of the injured member or body part which preexisted the claimed conditions. The 

physician was to also provide a rationalized medical opinion regarding causal relationship, if any, 

between the accepted work injury and the condition or conditions for which appellant was 

currently being treated. OWCP afforded appellant 30 days to submit the necessary evidence. 

By letter dated May 30, 2017, counsel contended that the evidence already of record was 

sufficient to establish that the claimed conditions were employment related, and that expansion of 

the acceptance of the claim was therefore warranted. He noted that the issue of claim expansion 

has never been developed. Counsel requested that OWCP review the entire case file and all of the 
5

medical evidence previously submitted and issue a decision on the claim expansion request. He

noted that “in the event that you find the medical evidence is not sufficient, please explain 

specifically why it is not.”

By decision dated June 6, 2017, OWCP denied appellant’s request to expand the 

acceptance of the claim to include additional diagnoses. It noted that “upon receipt of [the 

March 15, 2017] request, the evidence of record since the issuance of the [February 4, 2015] 

acceptance letter was thoroughly reviewed.” OWCP found that the evidence was insufficient to 

establish additional diagnoses causally related to the accepted injury as appellant had not provided 

a rationalized medical opinion from a qualified physician in response to its May 4, 2017 

development letter. 

LEGAL PRECEDENT

An employee has the burden of proof to establish that any specific condition for which 

compensation is claimed is causally related to the employment injury.4 Causal relationship is a 

medical issue, and the medical evidence required to establish causal relationship is rationalized 

medical evidence.5 The opinion of the physician must be based on a complete factual and medical 

background of the claimant, 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 employee.6 Neither the mere fact that a disease 

or condition manifests itself during a period of employment, nor the belief that the disease or 

condition was caused or aggravated by employment factors or incidents is sufficient to establish 

causal relationship.7

When an injury arises in the course of employment, every natural consequence that flows 

from that injury likewise arises out of the employment, unless it is the result of an independent 

intervening cause attributable to claimant’s own intentional misconduct.8 Thus, a subsequent 

injury, be it an aggravation of the original injury or a new and distinct injury, is compensable if it 

is the direct and natural result of a compensable primary injury.9 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.10

 

4 Kenneth R. Love, 50 ECAB 276 (1999).

5

Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000).

6 Leslie C. Moore, 52 ECAB 132 (2000); Gary L. Fowler, 45 ECAB 365 (1994).

7 Dennis M. Mascarenas, 49 ECAB 215 (1997).

8 Mary Poller, 55 ECAB 483, 487 (2004); 1 Arthur Larson & Lex K. Larson, The Law of Workers’ Compensation

10-1 (2006).

9 D.K., Docket No. 17-1549 (issued July 6, 2018). 

10 Charles W. Downey, 54 ECAB 421 (2003).
6

ANALYSIS

The Board finds that appellant has not established that the claimed additional conditions of 

concussion; postconcussion syndrome; post-traumatic migraine; occipital headaches and fatigue; 

occipital neuritis; neck sprain; cervical strain syndrome with cervicalgia; saccadic eye movement 

deficiency and vestibular dysfunction; cervical, lumbar, and brachial radiculopathy symptoms; 

ulnar neuropathy; and carpal tunnel syndrome were caused or aggravated by the August 16, 2013 

employment injury.11 

The opinion of a physician supporting causal relationship must be based on a complete 

factual and medical background, supported by affirmative evidence, must address the specific 

factual and medical evidence of record, and must provide medical rationale explaining the nature 

of the relationship between the diagnosed condition and the established incident or factor of 

employment.12 No such evidence is of record in this case.

The diagnostic studies of record did not provide a cause of any diagnosed conditions, and 

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.13 Moreover, when diagnostic 

testing is delayed, uncertainty mounts regarding the cause of the diagnosed condition and a 

question arises as to whether that testing in fact documents the injury claimed by the employee. 

The greater the delay in testing, the greater the likelihood that an event not related to employment 

has caused or worsened the condition for which the employee seeks compensation.14 Most of the 

diagnostic testing in this case was performed in February 2014, almost six months after the 

employment injury. Furthermore, none of the test results revealed a trauma-induced diagnosis.

Dr. Friedman’s reports are also insufficient to meet appellant’s burden of proof. He merely 

reported that appellant’s symptoms of dizziness with eye movement, headache and eyestrain 

associated with reading, and blurred distance vision began with a concussion injury on August 16, 

2013, and it seemed logical that they were the result of a brain injury. As noted, postconcussion 

syndrome has not been accepted as employment related. This report does not establish that the 

diagnosed conditions were directly caused or a consequence of the accepted injury.15 

On October 19, 2015 Dr. Crutchfield noted a current diagnosis of resolving post-traumatic 

occipital neuritis, with secondary headaches. It is unclear from his reports whether he considered 

 

11 With regard to the claimed RSD condition, the Board found in its prior decision that appellant had not met her 

burden of proof, as Dr. Sharma’s November 23, 2015 second opinion, which found no evidence of RSD, carried the 

weight of the medical evidence. Supra note 3. The Board’s prior findings with regard to the condition of RSD are 

res judicata. See A.C., Docket No. 18-0484 (issued September 7, 2018). With regard to the issue of expansion of the 

claim to include the additional condition of myofascial pain syndrome, OWCP did not address that condition in its 

June 6, 2017 decision. Thus, this issue is not presently before the Board. See 20 C.F.R. §§ 501.2(c) and 501.3.

12 Robert Broome, 55 ECAB 339 (2004).

13 Willie M. Miller, 53 ECAB 697 (2002).

14 Mary A. Ceglia, 55 ECAB 626 (2004).

15 Supra note 13. 
7

that the additional diagnoses of post-traumatic migraine headaches, vestibular dysfunction, and 

saccadic eye movement were related to postconcussion syndrome and/or occipital neuritis, which 

are not employment related. If not, other than his general conclusion that all diagnoses were caused 

by the August 16, 2013 employment injury, Dr. Crutchfield provided no additional rationale 

explaining exactly how the employment injury caused any of his diagnosed conditions. Medical 

conclusions unsupported by rationale are of diminished probative value and are insufficient to 

establish causal relation.16

Regarding the diagnoses of neck sprain, cervical strain syndrome with cervicalgia, cervical, 

lumbar, and brachial radiculopathy, as indicated above, Dr. Crutchfield provided insufficient 

rationale to support any of his diagnoses. 

OWCP referred appellant to Dr. Heitman, an orthopedic surgeon, and Dr. Sharma, a 

neurologist, for second opinion evaluations. Neither physician found additional employmentrelated conditions. Dr. Heitman advised that appellant had no continuing residuals of the accepted 

conditions, and Dr. Sharma advised that appellant had no neurological injuries due to the 

employment injury.

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 rationale explaining the 

nature of the relationship of the diagnosed condition and the specific employment factors or 

employment injury.17 The Board finds that appellant has not submitted sufficient rationalized 

medical evidence to establish causal relationship between the August 16, 2013 employment injury

and the claimed additional conditions of concussion; postconcussion syndrome; post-traumatic 

migraine; occipital headaches and fatigue; occipital neuritis, neck sprain; neck sprain; cervical 

strain syndrome with cervicalgia; saccadic eye movement deficiency and vestibular dysfunction; 

cervical, lumbar, and brachial radiculopathy symptoms; ulnar neuropathy; and carpal tunnel 

syndrome. 

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 that the 

acceptance of the claim should be expanded to include additional conditions of concussion; 

postconcussion syndrome; post-traumatic migraine; occipital headaches and fatigue; occipital 

neuritis; neck sprain; cervical strain syndrome with cervicalgia; saccadic eye movement deficiency 

and vestibular dysfunction; cervical, lumbar, and brachial radiculopathy symptoms; ulnar 

neuropathy; and carpal tunnel syndrome. 

 

16 J.B., Docket No. 08-1721 (issued January 26, 2009); Albert C. Brown, 52 ECAB 152 (2000).

17 C.O., Docket No. 10-189 (issued July 15, 2010).
8

ORDER

IT IS HEREBY ORDERED THAT the June 6, 2017 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: October 25, 2018

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