United States Department of Labor

Employees’ Compensation Appeals Board

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J.R., Appellant

and

DEPARTMENT OF HOMELAND SECURITY, 

U.S. CUSTOMS & IMMIGRATION SERVICE, 

New York, NY, Employer

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Docket No. 17-1297

Issued: October 11, 2017

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

ALEC J. KOROMILAS, Alternate Judge

JURISDICTION

On May 25, 2017 appellant filed a timely appeal from a May 12, 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 lumbar spine or right 

hip injury causally related to an accepted November 15, 2016 employment incident.

FACTUAL HISTORY

On November 21, 2016 appellant, then a 67-year-old immigration services analyst, filed a 

traumatic injury claim (Form CA-1) alleging that on November 15, 2016 he tripped and fell 

 

1

5 U.S.C. § 8101 et seq. 
2

while moving equipment, striking his right hip on the edge of a chair seat and landing on his 

right hip. He experienced the immediate onset of pain radiating from his right hip into his right 

lower extremity. A witness corroborated his account of events. Appellant stopped work on 

November 15, 2016. It is unclear from the case record whether he returned to work.

Dr. Susan Park, an attending Board-certified internist, held appellant off work from 

November 15 to 18, 2016.

The employing establishment issued an authorization for examination and treatment 

(Form CA-16) on November 21, 2016. In the attending physician’s report of the Form CA-16,

Dr. Park checked a box marked “yes” indicating that appellant had a prior history of back pain. 

She prescribed medication. Dr. Park discharged appellant from treatment effective 

November 29, 2016 and released him to light duty. She opined that appellant was totally 

disabled from work from November 15 to 29, 2016, and partially disabled from work from 

November 29 to December 5, 2016 or later. Dr. Park noted referring appellant to an orthopedist. 

In a December 7, 2016 letter, OWCP notified appellant of the additional evidence needed 

to establish his claim, including a report from his attending physician diagnosing an injury or 

condition causally related to the November 15, 2016 fall, and explaining how that incident was 

competent to cause the diagnosed injury or condition. It afforded appellant 30 days to submit 

such evidence.

In response, appellant submitted a November 30, 2016 letter from Dr. Park, noting her 

November 15 and 22, 2016 examinations. Dr. Park explained that appellant had a “history of 

herniated discs, severe ankylosing spondylitis, and arthritis. Due to the fall, these conditions 

were exacerbated causing extreme pain.” Dr. Park instructed appellant to rest at home and take 

prescribed pain medication. In a November 30, 2016 note, she held appellant off work until 

December 22, 2016 as his herniated discs and ankylosing spondylitis had “worsened since his 

fall.”

Appellant also provided November 30, 2016 x-rays of the lumbar spine demonstrating 

“[c]onfluent syndemodyte formation with ossification of the anterior and posterior longitudinal 

ligaments consistent with ankylosing spondylitis,” degenerative disc space narrowing at L3-4, 

fusion of the sacroiliac joints, dextroscoliosis, and no evidence of fracture. November 30, 2016 

x-rays of the right hip and pelvis demonstrated ankylosing spondylitis with fusion of the 

sacroiliac joints, and no evidence of fracture.

By decision dated January 11, 2017, OWCP denied appellant’s claim. It found that 

although he had established an employment incident on November 15, 2016, the medical 

evidence of record was insufficient to establish causal relationship as Dr. Park did not explain 

how and why the accepted fall would aggravate appellant’s preexisting lumbar and sacroiliac 

conditions or cause a new injury or condition.

On February 17, 2017 appellant requested reconsideration. He submitted a February 13, 

2017 letter from Dr. Jenny Diep, an attending Board-certified rheumatologist and internist,

noting that she had treated appellant since October 2015 for “chronic but quiescent” ankylosing 

spondylitis. Dr. Diep indicated that when appellant landed on his right lateral hip on 
3

November 15, 2016, he experienced “pain and discomfort at the site of trauma, with radiation 

from his hip down to his mid-calf.” This pain limited appellant’s “ability to walk and sit for 

prolonged periods of time.” Dr. Diep opined that “this pain was directly related to his fall and 

not due to his ankylosing spondylitis, because he was not experiencing any pain before the time 

of his accident.”

By decision dated May 12, 2017, OWCP denied modification, finding that Dr. Diep 

failed to diagnose an injury or condition causally related to the accepted November 15, 2016 fall. 

It explained that pain or discomfort alone does not satisfy the medical aspect of the fact of injury 

determination.

LEGAL PRECEDENT

An employee seeking benefits under FECA2has the burden of proof to establish the 

essential elements of his or her claim 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 specific condition and/or disability for which compensation is claimed are 

causally related to the employment injury.3 

To determine whether an employee sustained a traumatic injury in the performance of 

duty, OWCP begins with an analysis of whether fact of injury has been established. Generally, 

fact of injury consists of two components that must be considered conjunctively. First, the 

employee must submit sufficient evidence to establish that he or she actually experienced the 

employment incident that is alleged to have occurred.4 Second, the employee must submit 

sufficient evidence, generally only in the form of medical evidence, to establish that the 

employment incident caused a personal injury.5 

The medical evidence required to establish causal relationship is generally rationalized 

medical opinion evidence. Rationalized medical opinion evidence is medical evidence which 

includes a physician’s rationalized opinion on the issue of whether there is a causal relationship 

between the claimant’s diagnosed condition and the implicated employment factors. 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 claimant.6

 

2

Id.

3

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

4 Gary J. Watling, 52 ECAB 278 (2001).

5 Deborah L. Beatty, 54 ECAB 340 (2003).

6

Solomon Polen, 51 ECAB 341 (2000).
4

ANALYSIS

Appellant claimed that he injured his right hip at work on November 15, 2016 while 

moving equipment he tripped and fell, striking his hip on the edge of a chair seat and landing on 

his right hip. OWCP accepted that this incident occurred at the time, place, and in the manner 

alleged, but denied the claim as the medical evidence of record was insufficient to establish 

causal relationship.

In support of his claim, appellant provided reports from Dr. Park dated November 15 

to 30, 2016. Dr. Park opined that the November 15, 2016 fall exacerbated preexisting herniated 

discs, ankylosing spondylitis, and arthritis, causing extreme pain and disabling appellant from 

work from November 15 to December 22, 2016. She reiterated that appellant’s herniated disc

and ankylosing spondylitis “worsened since his fall.” However, Dr. Park did not provide her

medical reasoning explaining how the accepted mechanism of striking the edge of the chair then 

falling to the floor would have aggravated appellant’s preexisting disc herniations and 

ankylosing spondylitis. This lack of medical rationale reduces the probative value of Dr. Park’s

opinion.7

Dr. Diep, an attending Board-certified rheumatologist and internist, opined in a 

February 13, 2017 letter that the November 15, 2016 fall caused right hip and leg pain, 

superimposed on preexisting ankylosing spondylitis. However, pain is a symptom, not a specific 

medical diagnosis.8 Dr. Diep did not diagnose a distinct injury caused by the fall, or opine that 

the accepted work incident precipitated an objective worsening of ankylosing spondylitis. Her 

opinion is therefore insufficient to establish an injury causally related to the November 15, 2016 

employment incident.9

The Board notes that OWCP notified appellant by December 7, 2016 letter of the need to 

provide rationalized medical evidence from a physician supporting causal relationship. As 

appellant did not submit such evidence, the Board finds that he failed to meet his burden of 

proof.

On appeal appellant contends that the medical evidence supports that his claimed period 

of disability was causally related to the November 15, 2016 fall at work. As explained, the 

medical evidence does not contain a sufficient explanation of how and why the accepted work 

incident caused or aggravated any injury or condition.

Appellant may submit additional evidence or argument with a written request for 

reconsideration to OWCP within one year of the date of this merit decision, pursuant to 5 U.S.C. 

§ 8128(a) and 20 C.F.R. §§ 10.605 through 10.607.

 

7

See Frank D. Haislah, 52 ECAB 457 (2001) (medical reports not containing rationale on causal relationship are 

entitled to little probative value); Jimmie H. Duckett, 52 ECAB 332 (2001).

8 C.L., Docket No. 17-0249 (issued June 22, 2017).

9

Id.
5

CONCLUSION

The Board finds that appellant failed to meet his burden of proof to establish a lumbar 

spine or right hip injury causally related to an accepted November 15, 2016 employment

incident.

ORDER

IT IS HEREBY ORDERED THAT the decision of the Office of Workers’

Compensation Programs dated May 12, 2017 is affirmed.

Issued: October 11, 2017

Washington, DC

Christopher J. Godfrey, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Deputy Chief Judge

Employees’ Compensation Appeals Board

Alec J. Koromilas, Alternate Judge

Employees’ Compensation Appeals Board