United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

P.L., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Englishtown, NJ, Employer 

__________________________________________ 

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Docket No. 16-1445 

Issued: January 12, 2017 

Appearances: Case Submitted on the Record

James D. Muirhead, Esq., for the appellant1

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On July 5, 2016 appellant, through counsel, filed a timely appeal from an April 12, 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 over the merits of this case. 

ISSUE 

The issue is whether appellant met her burden of proof to establish an employmentrelated injury on February 8, 2014. 

 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

On appeal counsel asserts that the two incidents on February 8, 2014 occurred as alleged 

and that the medical evidence of record establishes causal relationship. 

FACTUAL HISTORY 

On February 8, 2014 appellant, then a 54-year-old rural carrier, filed a traumatic injury 

claim (Form CA-1), alleging that she felt bad pain in front and around the back under the 

shoulder blade of her right shoulder. She indicated that while performing work duties loading 

her mail truck, she felt sharp pain and a burning sensation. Appellant stopped work that day.3

 In 

statements dated February 8, 2014, she described right shoulder pain that occurred while loading 

her mail truck with regular, not heavy, parcels. Appellant indicated that she would like to see a 

physician that day, Saturday, or could wait until Monday. On an authorization for examination 

and/or treatment (Form CA-16) dated February 8, 2014, an employing establishment supervisor 

authorized medical treatment. 

Dr. Jeffrey G. Schlogl, Board-certified in emergency medicine, completed an emergency 

department report on February 8, 2014. He noted a history that appellant reported right shoulder 

muscle pain for the past month while lifting heavy parcels during the holiday season, and on that 

day, while sitting in her vehicle reaching over some ice to get to a mailbox, she developed sharp 

right anterior shoulder pain. Examination findings included tenderness along the top of the right 

shoulder. Right shoulder x-ray that day was negative for fracture. Appellant was discharged to 

home with a diagnosis of right shoulder tendinitis and advised not to work until seen by an 

orthopedic surgeon. On a separate disability slip Dr. Schlogl advised that she should not work 

for five days. Appellant did not return to work. 

On March 17, 2014 appellant was seen by Dr. David B. Dickerson, a Board-certified 

orthopedic surgeon, who noted a history that she was injured when a door hit the cart she was 

using to load her mail truck. He described her complaint of pain with motion and examination 

findings of tenderness and decreased range of motion of the right upper extremity. 

Dr. Dickerson diagnosed bicipital tenosynovitis and rotator cuff impingement. He recommended 

physical therapy and medication, and advised that appellant could not work until she could lift 

more than 25 pounds. 

By letter dated March 27, 2014, OWCP advised appellant that the evidence of record was 

insufficient to establish her claim. It informed her of the evidence needed to establish her claim. 

In an undated statement appellant explained that she initially had difficulty having her 

claim filed with OWCP and was then unable to find an orthopedic surgeon who would take 

OWCP patients until her March 17, 2014 appointment with Dr. Dickerson. She also submitted 

aftercare instructions from the February 8, 2014 emergency department visit. Appellant also 

 3

 The record contains one page of a handwritten Form CA-1 claim and a typed version. It also indicates that 

appellant had two prior claims: (1) a February 5, 2004 claim for a left shoulder condition, adjudicated by OWCP 

under File No. xxxxxx440 as a short form closure; and (2) a May 16, 2007 claim for a right shoulder condition, 

back, and leg injury, adjudicated under File No. xxxxxx183 as a short form closure. The instant claim was 

adjudicated under File No. xxxxxx742. 
3

filed claims for compensation (Form CA-7) for the period March 25 to April 18, 2014. These 

indicated that she received continuation of pay from February 9 to March 25, 2014. 

On April 16, 2014 Dr. Dickerson noted that appellant’s right shoulder pain had improved. 

He found tenderness and pain on right shoulder examination with full range of motion. 

Dr. Dickerson reiterated his diagnoses, recommended a right shoulder magnetic resonance 

imaging (MRI) scan, and advised that appellant could not work. 

By decision dated April 29, 2014, OWCP denied the claim. It found that an employment 

incident occurred on February 8, 2014, but that the medical evidence of record was insufficient 

to establish a medical condition causally related to the employment event. 

Appellant, through counsel, timely requested a hearing before an OWCP hearing 

representative. In an April 24, 2014 statement, received by OWCP on April 29, 2014, she 

indicated that on February 8, 2014, as she was leaving the building and pushing a mail cart out of 

a set of heavy, swinging doors, her loaded cart got caught, and the sudden stop jarred her body. 

Appellant recounted that she then adjusted the tub and pushed it through and, as she went out, 

the door swung back and hit the tub. She related that her truck door was already open and that 

when she picked up the first parcel to put it in the truck, she felt a sharp pain and burning 

sensation between the back of her right shoulder and inside the right shoulder blade. Appellant 

continued that she did not mention the door on her claim form because getting caught there, or 

having them swing back and hit your tub, was a common, everyday occurrence. She indicated 

that several years before her right shoulder hurt and she went to the emergency room where a 

calcified spot was found on x-ray. Appellant advised that she did not see an orthopedic surgeon 

immediately because she was not informed by the employing establishment regarding how to file 

a claim, and that, in addition to continued pain, she also had diminished right shoulder range of 

motion. 

On April 30, 2014 Dr. Dickerson advised that appellant could not work. A May 7, 2014 

MRI scan of the right shoulder demonstrated a full-thickness tear of the supraspinatus tendon and 

calcific bursitis. 

On May 20, 2014 appellant was seen by Dr. Anthony V. Petrosini, Board-certified in 

orthopedic surgery. Dr. Petrosini noted a history that on February 8, 2014 a mail cart she was 

pushing got caught in a door and, when she tried to push the cart, she felt right shoulder pain. 

Right shoulder examination demonstrated limited range of motion and tenderness over the biceps 

and greater tuberosity. Dr. Petrosini reviewed the MRI scan and diagnosed right shoulder rotator 

cuff tear, biceps synovitis, and calcific tendinitis. He recommended arthroscopic repair. 

Dr. Petrosini performed right shoulder arthroscopic repair of the supraspinatus tear, 

excision of calcific tendinitis, and biceps tenotomy on June 3, 2014. On June 13, 2014 he noted 

appellant’s report that she injured her right shoulder when loading a truck at work on 

February 8, 2014. Dr. Petrosini continued that she was moving a cart in a doorway, and as she 

tried to push the cart, she felt a sharp pain in the right shoulder. He described appellant’s 

medical and surgical treatment and opined that her diagnosis and surgical findings, which 

included a full-thickness rotator cuff tear, were related to the described work event. On 

November 18, 2014 Dr. Petrosini advised that she could return to work on November 20, 2014. 
4

At the hearing, held on December 3, 2014, appellant testified that on February 8, 2014 

she was rolling a tub of mail to her truck when it suddenly stuck in a doorway, and when she 

pushed it through, the door swung back and hit the tub. She continued that, when she picked up 

the first mail parcel, she had immediate pain and a burning sensation in her right shoulder. 

Appellant noted returning to full-time, full-duty, work on November 20, 2014. 

By decision dated January 26, 2015, an OWCP hearing representative affirmed the 

April 29, 2014 OWCP decision. He found that, as conflicting histories of the employment injury 

were presented to the physicians, the medical evidence was insufficient to establish causal 

relationship. 

On April 21, 2015 appellant, through counsel, requested reconsideration, and submitted 

statements dated March 19, 2015 in which she and her daughter, who drove appellant to the 

emergency room on February 8, 2014, described the events there. She maintained that 

Dr. Schlogl recorded an incorrect history, claiming that she felt a severe, sharp pain with a 

burning sensation as she was loading parcels into her truck. 

In a nonmerit decision dated May 6, 2015, OWCP denied appellant’s request for 

reconsideration. 

On January 13, 2016 appellant, through counsel, again requested reconsideration and 

submitted a January 7, 2016 report from Dr. Petrosini. Dr. Petrosini indicated that she reported 

that the employment injury occurred while she was loading her mail truck on February 8, 2014, 

and while pushing a cart of mail, it was caught in a door, and as she tried to push it through the 

door, she felt a sharp pain in her right shoulder. He described the MRI scan findings and 

appellant’s subsequent surgery on June 3, 2014. Dr. Petrosini noted that he had last seen her on 

October 21, 2014. He observed that, since he had not seen appellant recently, he could not 

comment on her current work status. Dr. Petrosini concluded “within a reasonable degree of 

medical certainty that the need for surgery for her rotator cuff tear was directly related to 

described work event.” 

In a merit decision dated April 12, 2016, OWCP found the medical evidence inconsistent 

regarding the February 8, 2014 employment incident and denied the claim. 

LEGAL PRECEDENT 

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

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

evidence,4

 including that he or she is an “employee” within the meaning of FECA and that he or 

she filed his or her claim within the applicable time limitation.5

 The employee must also 

 4

 J.P., 59 ECAB 178 (2007). 

5 R.C., 59 ECAB 427 (2008). 
5

establish that she sustained an injury in the performance of duty as alleged and that his disability 

for work, if any, was causally related to the employment injury.6

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether fact of injury has been established. 

There are two components involved in establishing fact of injury. First, the employee must 

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

the time, place, and in the manner alleged. Second, the employee must submit medical evidence 

to establish that the employment incident caused a personal injury.7

Causal relationship is a medical issue, and the medical evidence required to establish a 

causal relationship is rationalized medical evidence.8 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.9 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.10

ANALYSIS 

The evidence supports that, on February 8, 2014, appellant developed right shoulder pain. 

The Board, however, finds that the medical evidence of record is insufficient to establish that 

these incidents resulted in an employment injury. 

Medical evidence submitted to support a claim for compensation should reflect a correct 

history, and the physician should offer a medically sound explanation of how the claimed work 

event caused or aggravated the claimed condition.11 No physician did so in this case. 

Dr. Schlogl, the emergency medicine physician who saw appellant on February 8, 2014 

provided a history of right shoulder muscle pain occurring over the past month while lifting 

heavy parcels during the holiday season. He indicated that on February 8, 2014, while she was 

sitting in her vehicle and reaching over some ice to get to a mailbox, she developed sharp right 

anterior shoulder pain. Dr. Dickerson provided a history that appellant was injured when the 

 6 Id.; Elaine Pendleton, 40 ECAB 1143, 1145 (1989). 

7

 T.H., 59 ECAB 388 (2008). 

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

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

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

11 D.D., Docket No. 13-1517 (issued April 14, 2014). See also Douglas M. McQuaid, 52 ECAB 382 (2001) (the 

Board has long held that medical reports must be based on a complete and accurate factual and medical background, 

and medical opinions based on an incomplete or inaccurate history are of little probative value). 
6

door leading out of the building hit her mail cart. He did not further describe the circumstances 

of or explain how a door hitting her mail cart caused the claimed right shoulder injury. 

Likewise, Dr. Petrosini provided an insufficient history of injury. On May 20, 2014 he 

reported that on February 8, 2014, appellant was pushing a mail cart that got stuck in a door, and 

when she tried to move the cart, she felt pain in her shoulder. Dr. Petrosini noted MRI scan 

findings and diagnosed rotator cuff tear. Following the June 3, 2014 surgery, on June 13, 2014 

Dr. Petrosini first indicated that appellant injured her right shoulder on February 8, 2014 when 

she was loading a truck, but then related that, as she was moving a cart in a doorway and tried to 

push the cart, she felt a sharp pain in the right shoulder. 

The Board finds that the May 7, 2014 MRI scan did not provide a cause of any diagnosed 

conditions. 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

Thus, contrary to the assertions on appeal, these medical opinions are of diminished 

probative value. Each describes a different history of injury and none provides the necessary 

rationale explaining how and why the physician believes that the February 8, 2014 work 

incidents could result in a diagnosed condition. The medical evidence is, therefore, insufficient 

to establish that appellant’s diagnosed conditions were caused by the February 8, 2014 

employment incident.13 It is appellant’s burden to establish that a diagnosed condition is 

causally related to the February 8, 2014 incident. She submitted insufficient evidence to 

establish an injury caused by this incident. 

Where, as in this case, an employing establishment properly executes a Form CA-16, 

which authorizes medical treatment as a result of an employee’s claim for an employmentrelated injury, the CA-16 form 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 

terminated earlier by OWCP. See 20 C.F.R. § 10.300(c). 

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 her burden of proof to establish an 

employment-related injury on February 8, 2014. 

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

13 J.D., Docket No. 14-2061 (issued February 27, 2015). 
7

ORDER 

IT IS HEREBY ORDERED THAT the April 12, 2016 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: January 12, 2017 

Washington, DC 

 

 Christopher J. Godfrey, 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