United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

L.G., Appellant 

and 

DEPARTMENT OF VETERANS AFFAIRS, 

AUDIE L. MURPHY VETERANS 

ADMINISTRATION MEDICAL CENTER, 

San Antonio, TX, Employer 

__________________________________________ 

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Docket No. 15-1790 

Issued: February 17, 2016 

Appearances: Case Submitted on the Record

Alan J. Shapiro, 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 August 28, 2015 appellant, through counsel, filed a timely appeal from an April 15, 

2015 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. 

ISSUE 

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

disability on November 8, 2013 causally related to accepted employment injuries. 

On appeal counsel asserts that the April 15, 2015 decision is contrary to fact and law. 

 1

 5 U.S.C. § 8101 et seq. 
2

FACTUAL HISTORY 

On May 9, 2005 OWCP accepted that appellant, then a 47-year-old medical technologist, 

injured her lower back on August 13, 2004. The claim, adjudicated by OWCP under file number 

xxxxxx154, was accepted for lumbago, lumbar sprain, and thoracic or lumbosacral neuritis or 

radiculitis. On April 21, 2005 appellant again injured her back. OWCP adjudicated this claim 

under file number xxxxxx950 and accepted lumbar sprain. In decisions, under file number 

xxxxxx154, dated July 2 and August 8, 2007, OWCP denied appellant’s claims for compensation 

for April 11, 2007 and continuing. 

Appellant filed an additional claim for a May 16, 2010 injury, adjudicated by OWCP 

under file number xxxxxx028. OWCP accepted degeneration of lumbar or lumbosacral 

intervertebral disc, and displacement of lumbar intervertebral disc without myelopathy. Under 

file number xxxxxx028, in an August 25, 2011 decision, it denied appellant’s claim for 

compensation for the period June 15 through 24, 2011. These claims were combined, with the 

xxxxxx154 claim becoming the master file.2

 

On January 3, 2014 appellant filed a recurrence claim, Form CA-2a, under file number 

xxxxxx154. She indicated that she had been working six hours of restricted duty daily. 

Appellant related that the recurrence occurred on November 8, 2013, and that she stopped work 

on December 13, 2013. She explained that, because she was scheduled for an epidural steroid 

injection she had to discontinue heart medication, and the day after the procedure she had 

shortness of breath, increased blood pressure and perspiration, and that her kidneys stopped 

functioning. Appellant related that the problems persisted. 

The employing establishment indicated that appellant had been on restricted duty since 

the claims were accepted and was currently working six hours of restricted duty daily.3

 

Appellant thereafter submitted claims for compensation (Form CA-7) for the period August 1, 

2012 to August 15, 2015. The record indicates that she has preexisting lupus, coronary artery 

disease, and hypertension. 

By letter dated March 24, 2014, OWCP advised appellant of the evidence needed to 

support her recurrence claim. Appellant was asked to provide all medical records related to her 

condition and include a narrative report from her physician that explained the relationship 

between the accepted conditions and any consequential condition and/or disability. She was to 

complete an attached questionnaire regarding the claimed condition/disability. In a separate 

March 24, 2014 letter, OWCP advised appellant that it would not address her CA-7 claims until 

the recurrence claim had been adjudicated. 

Medical evidence submitted at that time, relevant to the claimed recurrence, included a 

number of reports from Dr. Yurii Borshch, Board-certified in anesthesiology and pain medicine. 

On September 20, 2013 Dr. Borshch reported seeing appellant for pain and medication 

management. He noted a past medical history of hypertension, anxiety disorder, heart disease, 

 2

 Appellant also has a number of additional claims that are not part of the present appeal. 

3

 Appellant was restricted to 10 pounds lifting; one-half hour bending, stooping, and twisting; and one-quarter 

hour pulling and pushing. 
3

lupus, depression, muscle spasms, heart attacks, heart stent, and incontinence, with active 

problems of anxiety, hypertension, brachial neuritis, chronic pain syndrome, enthesopathy of hip, 

lumbosacral spondylosis, long medication use, and lumbosacral neuritis radiculitis. Dr. Borshch 

advised that she would have an epidural steroid injection on her next visit and, in preparation she 

would stop Coumadin, an anticoagulant, and use injection therapy with Lovenox, also an 

anticoagulant. On October 17, 2013 he advised that appellant had a lumbar epidural steroid 

injection that day. Dr. Borshch described the procedure, advised that no complications were 

noted, and that appellant was discharged home with a designated driver.4

In reports dated October 23, 2013, Dr. Rodrigo David Cantu, Board-certified in family 

medicine, found that appellant could work no more than six hours daily due to chronic pain. On 

November 6, 2013 Dr. Shaun Jackson, Board-certified in physiatry and pain medicine, advised 

that appellant was seen for an electrodiagnostic study.5

On November 7, 2013 Dr. Borshch advised that appellant was seen to evaluate the 

outcome of the epidural steroid injection and that she reported that she was doing much better 

with pain control. He provided examination findings, noting no apparent cardiopulmonary 

distress. Dr. Borshch diagnosed lumbosacral neuritis, radiculitis, and chronic pain syndrome. 

On November 15, 2013 Dr. Cantu wrote that appellant should be excused from work from 

November 1 to 3, 2013 because she had a complication from treatment for her work-related 

injury.6

 On November 22, 2013 he reported that appellant’s blood pressure was elevated since 

her last steroid injection and that she had an appointment with a cardiologist the following week. 

Dr. Cantu advised that her high blood pressure was not related to her injection and not work 

related. 

On November 26, 2013 Dr. Jackie D. Stephenson, a Board-certified urologist, reported 

that anal sphincter testing revealed S1 radiculopathy with reduced anal sphincter response which 

was strongly suggestive that appellant’s neurological injury was the cause of her urinary 

incontinence. She recommended a urodynamic study. 

On December 24, 2013 Dr. Cantu noted that appellant was hospitalized due to 

complications including hypertension after an epidural steroid injection, had been out of work 

since December 13, 2013, and was totally disabled at that time. In reports dated January 3, 2014, 

he advised that appellant was under the care of a cardiologist, noting that she initially had severe 

hypertension, an electrocardiogram showed no acute change, and that after treatment was 

initiated she became hypotensive and required hospitalization. Dr. Cantu advised that she could 

not return to work because she felt fatigued and rundown. He diagnosed lumbar disc disease, 

herniated disc, and hypotension secondary to steroid injection for herniated disc. 

On January 14, 2014 Dr. Robert M. Saad, Board-certified in internal medicine and 

cardiology, reported that he followed appellant for coronary artery disease with a history of stent 

placement requiring anti-platelet therapy. He reported that, in preparation for an epidural steroid 

 4

 OWCP authorized an epidural injection on October 4, 2013. 

5

 A copy of the study is not found in the case record. 

6

 In a November 18, 2013 report, Dr. H. Mobley, an OWCP medical adviser, discussed appellant’s medication 

management. 
4

injection on October 17, 2013, she was required to stop Plavix, an anticoagulant, and begin 

bridging with Lovenox, a different anticoagulant. Appellant maintained that since the last 

injection she had developed multiple syndromes and side effects including labile blood pressure, 

shortness of breath, diaphoresis, and frequent headaches. Dr. Saad indicated that she had been 

hospitalized in January 2014 for further evaluation and testing. He concluded that appellant 

“attributes her current status of symptoms to last [epidural steroid injection].” 

On January 17, 2014 Dr. Cantu described appellant’s report that she was improved but 

still fatigued with intermittent dizziness. He noted that she had stent procedures in 2005 and 

2006. In a January 17, 2014 attending physician’s report, Dr. Cantu noted that appellant had 

severe hypertension after a steroid injection and then became hypotensive and had to be 

hospitalized. He advised that appellant could not work. 

On January 17, 2014 Dr. Borshch reported seeing appellant for follow-up evaluation of 

pain and medication management. He described examination findings and diagnosed 

lumbosacral neuritis radiculitis, chronic pain syndrome, and longtime medication use. 

In treatment notes and duty status reports dated February 3 to March 17, 2014, Dr. Cantu 

diagnosed herniated lumbar disc and hypotension and advised that appellant could not work. In 

correspondence dated March 19, 2014, he advised that he had treated appellant for her work 

injury since 2004 and that she had experienced urgency and incontinence since that date. 

Dr. Cantu asked that incontinence be accepted as employment related. He noted that 

Dr. Stephenson was treating appellant for incontinence and reported that a November 2013 

electrodiagnostic study conducted by Dr. Jackson concluded that appellant had lumbar nerve 

damage that caused her incontinence.7

 Dr. Jackson advised that appellant could not work. 

Dr. Borshch continued to submit reports describing appellant’s pain and medication 

management. On March 14, 2014 he noted appellant’s report that she had been held off work for 

some time due to cardiac issues. On June 12, 2014 Dr. Borshch reported that she had a lumbar 

epidural steroid injection that day. On July 2, 2014 he reported that appellant’s pain was 90 

percent improved. Dr. Borshch saw her in follow-up on August 11, 2014. 

In reports dated February 19 to June 25, 2014, Dr. Stephenson noted that appellant was 

having severe lumbar spasms, and that she had an urodynamic study which demonstrated 

moderate incontinence. 

In a July 11, 2014 report, Dr. Cantu advised that appellant had a recent acute anteroseptal 

myocardial infarction that required stenting of the left anterior descending artery on 

December 19, 2013. He opined, “It is our opinion the myocardial infarction occurred as a direct 

result of her stopping the Plavix prior to her epidural spinal injection for her work injury.” 

Dr. Cantu noted that appellant subsequently developed congestive heart failure “with volume 

overload after her myocardial infarction” which required continuous treatment for blood pressure 

 7 Supra note 5. 
5

and heart failure management. Appellant also submitted a publication regarding epidural 

injections and blood thinners.8

In a September 3, 2014 decision, OWCP denied the claim. It found the medical evidence 

insufficient to establish a December 13, 2013 recurrence because appellant had provided no 

medical evidence of disability due to an adverse reaction to epidural steroid injections. 

Appellant’s counsel timely requested a hearing before an OWCP hearing representative. 

He asked that OWCP accept acute anteroseptal myocardial infarction and neurogenic bladder. In 

reports dated September 11, 2014 to February 18, 2015, Dr. Borshch discussed physical 

examination findings and appellant’s pain and medication management. He reiterated his 

diagnoses. On November 20, 2014 Dr. Borshch performed lumbar epidural steroid injection. On 

February 18, 2015 he additionally diagnosed enthesopathy of knee and hip. 

In correspondence dated October 19, 2014, Dr. Stephenson advised that appellant had 

continued to have persistent back pain, with primary complaints of chronic lumbar back pain and 

severe urinary incontinence. She noted magnetic resonance imaging (MRI) scan and 

electrodiagnostic study findings, advising that they were consistent with a neurogenic bladder. 

Dr. Stephenson concluded that neurogenic bladder should be accepted. She also submitted 

reports dated August 27 to December 23, 2014 noting appellant’s complaints of muscle spasms 

and urinary continence. Dr. Stephenson advised that appellant could not work. 

A February 15, 2015 note with an illegible signature indicated that appellant had reached 

maximum medical improvement. 

In a report dated February 23, 2015, Dr. Francis X. Burch, Board-certified in internal 

medicine and rheumatology, noted that appellant had an extremely complex prior history with 

employment injuries in 2004 and 2005, lupus, and coronary artery disease. He reported 

reviewing May 26, 2010 and April 26, 2014 lumbar spine MRI scans and a November 6, 2013 

electrodiagnostic study.9

 Dr. Burch advised that he would continue the job restrictions provided 

by Dr. Stephenson. 

At a hearing held on March 9, 2015 counsel argued that, based on the medical evidence 

of record, the claim should be expanded to include incontinence and myocardial infarction. 

Appellant testified that in the fall of 2013 she had to stop taking Plavix because an epidural 

steroid injection was scheduled, and that in December 2013 she had a myocardial infarction. She 

stated that she had not returned to work and had applied for disability retirement. 

By decision dated April 15, 2015, an OWCP hearing representative found that the 

medical evidence of record was insufficient to establish a recurrence, noting that the record had 

very limited documentation from a physician regarding the December 2013 myocardial 

infarction and did not contain a well-reasoned opinion regarding the cause of the attack. She 

 8

 The record also includes an occupational disease claim and medical evidence regarding a June 18, 2014 fall in 

which appellant lacerated her thumb. OWCP adjudicated this claim separately. 

9 Supra note 5. The 2010 MRI scan demonstrated disc bulges at L3-4 and L5-S1 and multilevel facet joint 

arthrosis. A report of the April 26, 2014 study is not found in the case record. 
6

affirmed the September 3, 2014 decision. The hearing representative also informed counsel and 

appellant to pursue acceptance of additional conditions with OWCP. 

LEGAL PRECEDENT 

A recurrence of disability means an inability to work after an employee has returned to 

work, caused by a spontaneous change in a medical condition which had resulted from a 

previous injury or illness without an intervening injury or new exposure to the work environment 

that caused the illness.10 This term also means an inability to work when a light-duty assignment 

made specifically to accommodate an employee’s physical limitations due to her work-related 

injury or illness is withdrawn (except when such withdrawal occurs for reasons of misconduct, 

nonperformance of job duties or a reduction-in-force), or when the physical requirements of such 

an assignment are altered so that they exceed his or her established physical limitations.11

An individual who claims a recurrence of disability resulting from an accepted 

employment injury has the burden to establish that the disability is related to the accepted 

injury. This burden requires furnishing medical evidence from a physician who, on the basis of a 

complete and accurate factual and medical history, concludes that the disabling condition is 

causally related to the employment injury and supports that conclusion with sound medical 

reasoning.12 

ANALYSIS 

The Board finds that appellant failed to meet her burden of proof to establish a recurrence 

of disability on November 8, 2013 causally related to accepted employment injuries. The 

accepted injuries under this combined claim are lumbago, lumbar sprain, and thoracic or 

lumbosacral neuritis or radiculitis, degeneration of lumbar or lumbosacral intervertebral disc, and 

displacement of lumbar intervertebral disc without myelopathy. Appellant has not returned to 

work since the claimed recurrence. 

At the March 9, 2015 hearing, appellant testified that in the fall of 2013 she had to stop 

taking Plavix because an epidural steroid injection had been scheduled, and that in 

December 2013 she had a myocardial infarction. Any medical condition resulting from 

authorized examination or treatment may form the basis of a compensation claim for impairment 

or disability, regardless of the compensability of the original injury.13 The Board, however, finds 

that appellant has submitted insufficient medical evidence to support that the claimed recurrence 

was related to treatment for the accepted conditions. 

In July 2014 appellant submitted a publication regarding epidural injections and blood 

thinners. The Board has long held that excerpts from publications have little probative value in 

 10 20 C.F.R. § 10.5(x); see Theresa L. Andrews, 55 ECAB 719 (2004). 

11 Id. 

12 S.S., 59 ECAB 315 (2008). 

13 D.B., 58 ECAB 354 (2007); see Federal (FECA) Procedure Manual, Part 3 -- Medical, Authorizing 

Examination and Treatment, Chapter 3.300.2.b (February 2012). 
7

resolving medical questions unless a physician shows the applicability of the general medical 

principles discussed in the articles to the specific factual situation at issue in the case.14 There is 

no such opinion in this case. 

Dr. Saad, appellant’s attending cardiologist, did not report that appellant had a 

myocardial infarction and, as discussed below, appellant did not submit hospital records. 

Appellant did not respond to the development letter sent to her by OWCP on 

March 24, 2014. On the recurrence claim form filed on January 3, 2014, she asserted that on the 

day following the October 17, 2013 steroid injection she had shortness of breath, increased blood 

pressure, and that her kidneys stopped functioning. However, the first medical evidence of 

record that mentioned any reactions to the October 17, 2013 procedure is a November 15, 2013 

note from Dr. Cantu who advised that appellant had a complication from treatment. There is no 

contemporaneous medical evidence showing that appellant had an immediate reaction following 

the October 17, 2013 steroid injection. Likewise, although the record indicates that she was 

hospitalized on at least one occasion for hypotension and/or hypertension, and that she suffered a 

myocardial infarction, the record contains no records of the hospitalization(s) or treatment notes 

describing specific symptoms and sequelae. 

As noted above, appellant’s burden requires that she furnish medical evidence from a 

physician who, on the basis of a complete and accurate factual and medical history, concludes 

that the disabling condition is causally related to the employment injury and who supports that 

conclusion with sound medical reasoning.15 Where no such rationale is present, the medical 

evidence is of diminished probative value.16

The record indicates that Dr. Borshch performed an epidural steroid injection on 

October 17, 2013. At that time he advised that there were no complications and appellant was 

discharged home. On November 7, 2013 Dr. Borshch advised that appellant reported that she 

was doing much better with pain control. He provided physical examination findings, noting no 

apparent cardiopulmonary distress. While Dr. Borshch noted on March 14, 2014 that appellant 

reported that she had been off work for some time due to cardiac issues, he provided no opinion 

or rationale to support disability. In his later reports, Dr. Borshch merely described appellant’s 

pain and medication management and also diagnosed enthesopathy of knee and hip, conditions 

that are not accepted by OWCP. 

As noted above, the earliest mention by a physician that appellant had complications 

from the October 17, 2013 epidural steroid injection is a November 15, 2013 note in which 

Dr. Cantu reported that appellant should be excused from work from November 1 to 3, 2013 

because she had a complication from treatment for her work-related injury. On November 22, 

2013 he reported a history that appellant’s blood pressure had been elevated since her last steroid 

injection and that she had a cardiology appointment the following week. Dr. Cantu advised that 

her high blood pressure was not related to her injection and not work related. On December 24, 

 14 Roger G. Payne, 55 ECAB 535 (2004). 

15 Supra note 12. 

16 Mary A. Ceglia, 55 ECAB 626 (2004). 
8

2013 he noted that appellant was hospitalized due to complications including hypertension after 

an epidural steroid injection and had not worked since December 13, 2013, was under a 

cardiologist’s care, and could not work because she felt fatigued and rundown. On March 19, 

2014 Dr. Cantu advised that he had treated appellant for a work injury since 2004 and that she 

had experienced urgency and incontinence since that date. He reported Dr. Stephenson’s 

findings and conclusions asked that incontinence be accepted. On July 11, 2014 Dr. Cantu 

concluded that appellant’s myocardial infarction resulted from her ceasing to take Plavix prior to 

the epidural spinal injection for her employment injury, thereby resulting in blood pressure and 

heart failure management. He continued to advise that appellant could not work. However, 

Dr. Cantu did not explain why he initially opined that appellant’s elevated blood pressure was 

not related to the epidural steroid injection and later changed his mind. He did not provide any 

medical rationale explaining how and why appellant was disabled due to treatment for the effects 

of an employment injury. Medical opinions based upon an incomplete history or which are 

speculative or equivocal in character have little probative value.17 

The opinion of a physician supporting causal relationship must be one of reasonable 

medical certainty that the condition for which compensation is claimed is causally related to 

federal employment and such relationship must be supported with affirmative evidence, 

explained by medical rationale, and be based upon a complete and accurate medical and factual 

background of the claimant.18 Neither Dr. Borshch nor Dr. Cantu provided sufficient rationale. 

Their opinions are, therefore, of diminished probative value.19 

Although Dr. Stephenson advised that appellant could not work, she diagnosed urinary 

incontinence caused by the employment injury, and this has not been accepted. She provided no 

opinion regarding whether appellant was disabled due to the accepted conditions and exhibited 

no knowledge of the modified duties she was performing when she stopped work. As noted by 

the OWCP hearing representative in the April 15, 2015 decision, appellant should pursue 

acceptance of this additional condition with OWCP. Dr. Stephenson’s opinion is insufficient to 

establish a recurrence of disability on November 8, 2013. 

Dr. Saad, an attending cardiologist, reported that since an epidural injection appellant had 

developed multiple syndromes and side effects including labile blood pressure, shortness of 

breath, diaphoresis, and frequent headaches. He noted that she was hospitalized in January 2014 

for further evaluation and testing. In regard to causal relationship, Dr. Saad merely advised that 

appellant attributed her current symptoms to her last epidural steroid injection. He provided no 

personal conclusion as to the cause of her symptoms and hospitalization. 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.20 

 17 Frank Luis Rembisz, 52 ECAB 147 (2000). 

18 Patricia J. Glenn, 53 ECAB 159 (2001). 

19 See T.M., Docket No. 08-975 (issued February 6, 2009). See also supra note 12 (the Board has held that 

contemporaneous evidence is entitled to greater probative value than later evidence). 

20 Willie M. Miller, 53 ECAB 697 (2002). 
9

Likewise, Dr. Burch’s opinion is of insufficient rationale to establish a November 8, 2013 

recurrent. In his February 23, 2015 report, Dr. Burch merely noted that appellant had an 

extremely complex prior history, and, without further explanation, advised that he would 

continue the job restrictions provided by Dr. Stephenson. 

As appellant did not submit sufficient medical evidence to establish a recurrence of 

disability on November 8, 2013 causally related to accepted employment injuries, she did not 

meet her burden of proof.21

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 a recurrence 

of disability on November 8, 2013 causally related to accepted employment injuries. 

ORDER 

IT IS HEREBY ORDERED THAT the April 15, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: February 17, 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 

 21 Supra note 16.