United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

K.W., Appellant 

and 

DEPARTMENT OF DEFENSE, DEFENSE 

LOGISTICS AGENCY, New Cumberland, PA, 

Employer 

__________________________________________ 

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Docket No. 16-1176 

Issued: November 2, 2016 

Appearances: Case Submitted on the Record

Appellant, pro se 

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 May 11, 2016 appellant filed a timely appeal from a March 17, 2016 merit decision of 

the Office of Workers’ Compensation Programs (OWCP). Pursuant to the Federal Employees’ 

Compensation Act1 (FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over 

the merits of this case.2

ISSUE 

The issue is whether appellant met her burden of proof to establish left shoulder and neck 

injuries causally related to the June 4, 2015 employment incident. 

 1

 5 U.S.C. § 8101 et seq.

2

 Appellant submitted new evidence on appeal. The Board’s jurisdiction however is limited to reviewing the 

evidence that was before OWCP at the time of its final decision. Therefore, the Board lacks jurisdiction to review 

this new evidence on appeal. See 20 C.F.R. § 501.2(c)(1). 
2

On appeal, appellant contends that the medical evidence of record is sufficient to 

establish that she sustained an injury causally related to the June 2015 employment incident. 

FACTUAL HISTORY 

On June 8, 2015 appellant, then a 54-year-old materials examiner and identifier, filed a 

traumatic injury claim (Form CA-1) alleging that on June 4, 2015 she pulled a muscle in her left 

shoulder while moving boxes from one pallet to another. 

In a work restriction evaluation form dated June 4, 2015, Dr. Christina Balum Maier, an 

employing establishment physician Board-certified in family medicine, placed appellant off 

work on that date. She advised that appellant could perform light-duty work eight hours a day 

with restrictions from June 5 to 9, 2015. Dr. Maier concluded that she could return to full-duty 

work on June 10, 2015. In a June 10, 2015 work restriction evaluation, she reported that 

appellant could perform light-duty work with restrictions through June 24, 2015. By prescription 

of the same date, Dr. Maier ordered physical therapy to treat her work-related left shoulder and 

neck pain and muscle spasm. 

Reports and therapy notes from appellant’s physical therapists addressed the treatment of 

appellant’s cervical condition from June 29 to July 31, 2015. A June 29, 2015 report from a 

physical therapist provided findings on examination and diagnosed appellant with work-related 

neck and left shoulder pain. 

By letter dated August 19, 2015, OWCP notified appellant of the deficiencies of her 

claim and afforded her 30 days to submit additional medical and factual evidence. It also 

requested that the employing establishment submit medical evidence if appellant had been 

treated at its medical facility. 

Reports and therapy notes from appellant’s physical therapists addressed appellant’s 

treatment and work restrictions from July 2 to September 2, 2015 and excused her from work on 

intermittent dates from August 10 to September 21, 2015 for her medical appointments. 

In a July 28, 2015 prescription, Dr. Maier noted work-related left neck and shoulder pain 

and sprain. 

On August 28, 2015 Dr. Balint Balog, an attending Board-certified orthopedic surgeon, 

reported that appellant could return to work on that date with restrictions related to her cervical 

spine. In an excuse slip of the same date, he excused her from work for her appointment on that 

date. 

In a September 3, 2015 prescription, Dr. Kimberlee P. Young, a Board-certified family 

practitioner, recommended that appellant participate in a physical fitness program. She placed 

her on light duty due to her neck condition. 

By decision dated September 21, 2015, OWCP accepted that the September 4, 2015 

incident occurred as alleged. However, it denied appellant’s traumatic injury claim as it did not 

receive medical evidence from a physician that established neck and left shoulder conditions 

causally related to the accepted employment incident. 
3

Appellant provided an August 28, 2015 report from Dr. Balog who noted that appellant’s 

neck, right shoulder, and right arm pain were first reported on June 4, 2015. Dr. Balog provided 

findings on physical examination and diagnostic x-ray findings of the cervical spine and left 

shoulder. He diagnosed left upper extremity pain, most likely secondary to a cervical spine 

sprain and cervical radiculitis. Dr. Balog concluded that appellant’s left shoulder pain was 

secondary to her cervical spine spondylosis. In a September 25, 2015 report, he noted that 

appellant sustained a cervical injury on June 4, 2015. Dr. Balog advised that she could return to 

work with restrictions on the date of his report. In a September 25, 2015 summary of visit, he 

noted appellant’s problems which included shoulder joint and limb pain and cervical spondylosis 

without myelopathy. In an excuse slip of the same date, Dr. Balog excused appellant from work 

on that date. 

On October 7, 2015 appellant requested a review of the written record by an OWCP 

hearing representative regarding the September 21, 2015 decision. By letter dated September 28, 

2015, she contended that she sustained work-related left shoulder and neck injuries on 

June 4, 2015. 

In a June 4, 2015 report, Dr. Maier provided a history that appellant had pain from desk 

ergonomics at work. She provided findings on examination and reiterated her diagnosis of 

muscle spasms and opinion that appellant could return to limited-duty work with restrictions 

from June 5 to 9, 2015. In a June 20, 2014 sick slip, Dr. Maier recommended that appellant 

undergo an ergonomic evaluation. 

In a June 10, 2015 report, Dr. Maier provided a history that appellant experienced 

ergonomic overexertion that resulted in left neck and shoulder spasm and pain without direct 

injury. She provided examination findings and diagnosed muscle spasms in the neck and muscle 

spasms. Dr. Maier concluded that appellant had occupational ergonomic overexertion secondary 

to worksite ergonomics/overexertion. 

On July 28, 2015 Dr. Richard E. Taggart, Board-certified in family and emergency 

medicine, noted seeing appellant in follow-up of left neck and shoulder pain “from ergonomics 

at her position.” He noted that physical therapy had not improved her condition. Appellant 

reported neck pain radiating to her shoulders and advised that the pain made it difficult to 

perform her job duties. Dr. Taggart noted findings and diagnosed shoulder sprain and neck 

muscle spasms. He recommended continued work restrictions and physical therapy. The report 

noted that appellant was seen for a “workman’s comp claim.” 

In a summary of visit dated July 31, 2015, Dr. Balog indicated that appellant’s next 

medical appointment was scheduled for August 28, 2015. In a September 25, 2015 report, he 

examined appellant and diagnosed cervical radiculitis, left more than right that was greater than 

three months in duration and positionally related. On November 6, 2015 Dr. Balog again noted 

that appellant sustained a cervical injury on June 4, 2015. He advised that she could return to 

work with restrictions. In a December 1, 2015 excuse slip, Dr. Balog released appellant to return 

to work with no restrictions on December 3, 2015. 

In a progress note dated September 30, 2015, Dr. Young listed appellant’s medications. 

Also submitted were additional records from the physician assistant and physical therapists. 
4

By decision dated March 17, 2016, an OWCP hearing representative affirmed the 

September 21, 2015 decision. She found that the medical evidence was insufficient to establish 

that appellant’s diagnosed medical conditions were causally related to the accepted June 4, 2015 

employment incident. 

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 

evidence3

 including that he or she sustained an injury in the performance of duty and that any 

specific condition or disability for work for which he or she claims compensation is causally 

related to that employment injury.4

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.5

 

There are two components involved in establishing the 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.6 

The second component is whether the employment incident caused a personal injury and 

generally can be established only by medical evidence.7 The evidence required to establish 

causal relationship is rationalized medical opinion evidence, based upon complete factual and 

medical background, showing a causal relationship between the claimed condition and the 

identified factors.8 The belief of the claimant that a condition was caused or aggravated by the 

employment is insufficient to establish a causal relationship.9

ANALYSIS 

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

injury caused by the June 4, 2015 employment incident. Appellant failed to submit sufficient 

medical evidence to establish that she had left shoulder and neck injuries causally related to the 

accepted employment incident. 

 3 J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968). 

4 G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989). 

5 S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005). 

6 Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968). 

7 John J. Carlone, 41 ECAB 354 (1989); see 5 U.S.C. § 8101(5) (injury defined); 20 C.F.R. §§ 10.5(ee), 10.5(q) 

(traumatic injury and occupational disease defined, respectively). 

8 Lourdes Harris, 45 ECAB 545 (1994); see Walter D. Morehead, 31 ECAB 188 (1979). 

9 Kathryn Haggerty, 45 ECAB 383, 389 (1994). 
5

Appellant submitted a series of reports from Dr. Maier. In her prescriptions dated 

June 10 and July 28, 2015, she found that appellant had work-related left shoulder and neck pain 

and sprain. Dr. Maier’s prescriptions are unsupported by rationale and are conclusory. Medical 

opinions which contain no rationale or explanation are of little probative value.10 Dr. Maier’s 

June 4, 2015 report found that appellant had muscle spasms and could perform limited-duty 

work with restrictions. Appellant informed Dr. Maier that her pain resulted from desk 

ergonomics at work and reported findings on physical examination. The Board notes that 

appellant did not attribute her claimed medical condition to the accepted June 4, 2015 work 

incident. Moreover, Dr. Maier did not offer her own opinion as to whether appellant’s muscle 

spasms were caused or aggravated by the accepted June 4, 2015 work incident. Medical 

evidence that does not offer any opinion regarding the cause of an employee’s condition is of 

limited probative value.11 

Appellant also submitted reports from Dr. Balog. In his September 25 and November 6, 

2015 reports, Dr. Balog related that she sustained a cervical injury on June 4, 2015. He advised 

that appellant could return to work with restrictions. Dr. Balog did not provide a history of 

injury, examination findings, a firm diagnosis of a cervical condition, or medical rationale which 

explained the nature of the relationship between the diagnosed condition and the accepted 

June 4, 2015 employment incident. As such, his report is of diminished probative value and is 

insufficient to establish appellant’s claim.12 In another September 25, 2015 report, Dr. Balog 

found that appellant had cervical radiculitis. He opined that she had this condition for more than 

three months and it was positionally related. Dr. Balog’s opinion on causal relationship is of 

limited probative value as it is not supported by rationale and is conclusory.13 He did not explain 

how moving boxes from one pallet to another pallet on June 4, 2015 caused the diagnosed 

cervical condition. 

Dr. Balog’s August 28, 2015 report provided a history that appellant first reported her 

neck, right shoulder, and right arm pain on June 4, 2015. He provided findings on physical 

examination and diagnostic testing and diagnosed left upper extremity pain. Dr. Balog opined 

that appellant’s condition was most likely secondary to cervical sprain and cervical radiculitis. 

He concluded that her left shoulder pain was secondary to her cervical spine spondylosis. 

Dr. Balog did not provide a firm medical diagnosis for appellant’s condition as pain is a 

description of a symptom and not considered a compensable medical diagnosis.14 Moreover, he 

attributed her left upper extremity pain to her cervical conditions, but failed to provide an 

opinion addressing whether these conditions were caused or aggravated by the June 4, 2015 

 10 F.T., Docket No. 09-919 (issued December 7, 2009) (medical opinions not fortified by rationale are of 

diminished probative value); Sedi L. Graham, 57 ECAB 494 (2006) (medical form reports and narrative statements 

merely asserting causal relationship generally do not discharge a claimant’s burden of proof). 

11 C.B., Docket No. 09-2027 (issued May 12, 2010). 

12 See T.G., Docket No. 13-76 (issued March 22, 2013); Lee R. Haywood, 48 ECAB 145 (1996). 

13 F.T., supra note 10. 

14 K.W., Docket No. 12-1590 (issued December 18, 2012). 
6

employment incident.15 Other reports from Dr. Balog are of limited probative value as this 

evidence did not provide a history of injury, examination findings, a firm diagnosis of a medical 

condition, or medical rationale on the causal relationship between the diagnosed condition and 

the accepted June 4, 2015 employment incident. 

Dr. Taggart’s July 28, 2015 report diagnosed shoulder sprain and neck muscle spasms. 

He noted seeing appellant in follow-up of left neck and shoulder pain “from ergonomics at her 

position.” The report noted that appellant was seen for a “workman’s comp claim.” Dr. Taggart, 

however, did not address how work duties on June 4, 2015 caused or aggravated the diagnosed 

conditions. As he provided no medical rationale to support causal relationship, his report is of 

limited probative value.16

Other medical reports of record are of limited probative value as they did not offer a 

specific opinion on any causal relationship between the diagnosed medical condition and the 

accepted June 4, 2015 employment incident.17 

Also of record are reports from physical therapists and a physician assistant. However, 

these records are of no probative medical value as neither physical therapists nor physician 

assistants are considered physicians as defined under FECA.18

The Board finds that appellant has failed to submit any rationalized probative medical 

evidence to establish that she sustained left shoulder and neck injuries causally related to the 

June 4, 2015 employment incident. Appellant did not meet her burden of proof. 

On appeal, appellant contends that the medical evidence of record is sufficient to 

establish that she sustained an injury causally related to the June 2015 employment incident. As 

found above, the Board finds that appellant did not submit any rationalized probative medical 

evidence supporting a causal relationship between her diagnosed left shoulder and neck 

conditions and the established employment incident. 

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. 

 15 Supra note 11. 

16 See supra note 10. 

17 See J.F., Docket No. 09-1061 (issued November 17, 2009) (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). 

18 5 U.S.C. § 8101(2); A.C., Docket No. 08-1453 (issued November 18, 2008) (physical therapists); Sean 

O’Connell, 56 ECAB 195 (2004) (physician assistants). See also Gloria J. McPherson, 51 ECAB 441 (2000); 

Charley V.B. Harley, 2 ECAB 208, 211 (1949) (a medical issue such as causal relationship can only be resolved 

through the submission of probative medical evidence from a physician). 
7

CONCLUSION 

The Board finds that appellant has failed to meet her burden of proof to establish left 

shoulder and neck injuries causally related to the June 4, 2015 employment incident. 

ORDER 

IT IS HEREBY ORDERED THAT the March 17, 2016 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: November 2, 2016 

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