United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

R.F., Appellant

and

DEPARTMENT OF THE AIR FORCE, 

SEYMOUR JOHNSON AIR FORCE BASE, NC, 

Employer

__________________________________________

)

)

)

)

)

)

)

)

)

Docket No. 18-0408

Issued: August 10, 2018

Appearances: Case Submitted on the Record

Appellant, pro se

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 December 18, 2017 appellant filed a timely appeal from a July 28, 2017 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 his burden of proof to establish a right shoulder and arm

injury causally related to the accepted November 23, 2015 employment incident.

 

1 5 U.S.C. § 8101 et seq.
2

FACTUAL HISTORY

On September 12, 2016 appellant, then a 62-year-old school liaison officer, filed a 

traumatic injury claim (Form CA-1) alleging that he injured his right shoulder and arm when he 

set up and removed 200 chairs and tables on November 23, 2015 while in the performance of duty. 

By development letter dated September 21, 2016, OWCP informed appellant that 

additional evidence was needed to establish his claim. It advised him that he should submit a 

medical report from his physician with an explanation as to how the alleged work incident caused 

or aggravated the claimed condition. OWCP afforded appellant 30 days to submit the necessary 

evidence. 

In a September 21, 2016 statement, appellant reported that on November 19 and 23, 2015 

he had to set up chairs and tables for meetings, and thereafter on November 24, 2015 he noticed

pain and stiffness in his right arm. He also indicated that on November 25, 2015, while boarding 

an airplane for the Thanksgiving holiday, he felt a sharp pain in his right shoulder when he lifted 

his suitcase into the overhead bin. Appellant reported that he continued to experience pain and 

saw his family physician on December 29, 2015 who diagnosed bursitis and referred him for 

physical therapy. He indicated that he wanted to submit the claim prior to his retirement on 

September 30, 2016. 

W.J., a coworker, provided a witness statement dated September 22, 2016. He indicated 

that on November 23, 2015 he, along with appellant and another coworker, had to set up a meeting 

which required placing approximately 200 chairs and large tables for the event. W.J. noted that 

appellant mentioned that his arm and shoulder were hurting during the set up process. 

On an OWCP claim questionnaire, signed on October 18, 2016, appellant indicated that he 

had been seen by Dr. Donald K. Clarke, a family practice physician, on December 29, 2015 for 

continuing right shoulder and upper arm pain and stiffness. He related that he had never 

experienced right shoulder pain prior to the employment injury. 

In an October 18, 2016 report, Dr. Clarke indicated that he saw appellant on December 29,

2015 for shoulder pain. He noted that appellant advised him that the injury occurred on 

November 23, 2015 while lifting furniture at work. Dr. Clarke described examination findings of 

right shoulder tenderness and pain with abduction against resistance, and good range of motion 

and stability. He diagnosed right shoulder bursitis and recommended physical therapy. Dr. Clarke 

reported that he next saw appellant again on February 1, 2016 when appellant reported continued 

pain when using his computer, and saw him a third time on September 7, 2016 when he reported 

worsening shoulder pain. Shoulder examination at that time demonstrated increased tenderness 

and pain with movement. Dr. Clarke referred appellant to orthopedics and reported that a magnetic 

resonance imaging (MRI) scan was performed. He concluded that appellant’s diagnosed bursitis

was an overuse syndrome, and that appellant’s description of the reported work incident was 

consistent with his symptoms and diagnosis. Dr. Clarke attached unsigned treatment notes. On 

September 7, 2016 he noted a history that appellant helped someone move over the weekend and 

subsequently had a lot of pain. 
3

A September 26, 2016 MRI scan of the right shoulder demonstrated minimal undersurface 

fraying/tiny partial tear of the anterior fibers of the supraspinatus at insertion, no full-thickness 

rotator cuff tear, probable subacromial, subdeltoid bursitis, question tiny amount of calcific 

tendinitis within the subscapularis tendon, moderate acromioclavicular joint degenerative 

osteoarthrosis, probable superior labral tear, and diminutive posterior labrum. 

By decision dated October 26, 2016, OWCP found that the November 23, 2015 

employment incident occurred as alleged, but the medical evidence of record was insufficient to 

establish causal relationship between the accepted incident and the diagnosed right shoulder

conditions. 

On November 1, 2016 OWCP noted that it had not reviewed all of the evidence of record 

when it issued the October 26, 2016 decision. On November 4, 2016 appellant requested 

reconsideration. 

In a subsequent merit decision dated December 12, 2016, OWCP reviewed all evidence 

submitted. It found that on November 23, 2015 appellant was required to stack and replace chairs 

at work. However, OWCP found Dr. Clarke’s October 18, 2016 report contained insufficient 

rationale to establish that this incident caused the diagnosed shoulder bursitis because he also 

referenced computer use and indicated that bursitis was an overuse syndrome. 

On May 25, 2017 appellant requested reconsideration. He submitted reports from

Dr. Gregory S. Bauer, a Board-certified orthopedic surgeon, who first saw appellant on 

September 19, 2016 and reported a history that appellant first felt right shoulder pain when he 

unloaded multiple chairs and tables at work on November 23, 2015. Dr. Bauer described 

examination findings of mild tenderness over the biceps tendon and greater tuberosity and limited 

right shoulder range of motion. He reviewed x-rays that showed mild narrowing of the 

glenohumeral joint. Dr. Bauer diagnosed right shoulder pain secondary to adhesive capsulitis. On 

October 3, 2016 he reviewed the right shoulder MRI scan, noting no apparent rotator cuff tear and 

subacromial and subdeltoid bursitis and likely adhesive capsulitis. 

On October 31, 2016 appellant was seen by Dr. Hector M. Pedraza, a Board-certified 

orthopedist and associate of Dr. Bauer, who reported that appellant’s shoulder pain had improved. 

On May 11, 2017 Dr. L. Davis Frederick, Board-certified in orthopedic surgery and an 

associate of Dr. Bauer, noted that appellant’s shoulder had improved with conservative care, which 

was continued. 

Appellant also forwarded photographs of the chairs and tables that he maintained caused 

his injury. 

By decision dated July 28, 20017, OWCP reviewed the merits of appellant’s claim and

denied modification of the prior decisions. It found that the medical evidence of record did provide 

a rationalized medical opinion causally relating his diagnosed conditions to the accepted 

employment incident. 
4

LEGAL PRECEDENT

An employee seeking benefits under FECA2 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.3

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 he or 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.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

ANALYSIS

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

and arm injury causally related to the accepted November 23, 2015 employment incident.

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 

 

2

Id.

3 Kathryn Haggerty, 45 ECAB 383, 388 (1994).

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

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).
5

event caused or aggravated the claimed condition.8 The Board finds that no physician did so in 

this case. 

The September 26, 2016 MRI scan provided diagnostic findings; however, this report is 

insufficient to establish appellant’s claim because it did not provide an opinion on the causal

relationship of the conditions found on diagnostic testing and the accepted work injury. Therefore, 

this report is of limited probative value in establishing causal relationship.9

Likewise, Dr. Bauer, Dr. Pedraza, and Dr. Frederick did not include an opinion as to the 

cause of any diagnosed condition. 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.10 

In his report dated October 18, 2016, Dr. Clarke noted that on December 29, 2015 appellant 

reported that right shoulder pain occurred on November 23, 2015 while lifting furniture at work. 

He diagnosed right shoulder bursitis. When he next saw appellant on February 1, 2016, Dr. Clarke

noted appellant’s complaint of continued pain with using his computer, and that he reported 

worsening shoulder pain when seen on September 7, 2016. He concluded that appellant’s 

diagnosed bursitis was an overuse syndrome, adding that appellant’s description of the reported 

work incident was consistent with his symptoms and diagnosis. Dr. Clarke, however, did not 

provide specific rationale as to how the November 23, 2015 employment incident caused 

appellant’s right upper extremity condition. Thus, his opinion on causal relationship fails to 

provide a sufficient explanation as to the mechanism of injury pertaining to this traumatic injury 

claim, namely, how the moving chairs and tables on November 23, 2015 caused a right shoulder 

condition, which he described as caused by overuse.

11

 Moreover, appellant described several

incidents when he felt pain lifting a suitcase and also reported increased pain after he helped 

someone to move. 

Medical reports without adequate rationale on causal relationship are of diminished 

probative value and do not meet an employee’s burden of proof.12 The opinion of a physician 

supporting causal relationship must rest on a complete factual and medical background supported 

by affirmative evidence, address the specific factual and medical evidence of record, and provide 

medical rationale explaining the relationship between the diagnosed condition and the established 

incident of employment.13 

 

8 D.D., Docket No. 13-1517 (issued April 14, 2014).

9 See Michael E. Smith, 50 ECAB 313 (1999); S.B., Docket No. 17-0254 (issued July 20, 2018) (diagnostic studies, 

on their own, are of limited probative value as they do not address whether the employment incident caused any of 

the diagnosed conditions).

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

11 S.W., Docket No. 08-2538 (issued May 21, 2009).

12 D.E., Docket No. 17-1874 (issued February 9, 2018).

13 Supra note 5.
6

It is appellant’s burden of proof to establish that a diagnosed condition is causally related 

to the accepted November 23, 2015 employment incident. As he submitted insufficient evidence 

to establish an injury caused by his accepted employment incident, he has failed to meet his burden 

of proof.

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 right shoulder

and arm injury causally related to the accepted November 23, 2015 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the July 28, 2017 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: August 10, 2018

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