United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

V.D., Appellant 

and 

DEPARTMENT OF THE ARMY, U.S. ARMY 

MEDICAL RESEARCH INSTITUTE OF 

INFECTIOUS DISEASES, Fort Detrick, MD, 

Employer 

__________________________________________ 

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Docket No. 16-1345 

Issued: September 27, 2017 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

COLLEEN DUFFY KIKO, Judge 

ALEC J. KOROMILAS, Alternate Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On June 10, 2016 appellant filed a timely appeal from a December 14, 2015 merit 

decision of the Office of Workers’ Compensation Programs (OWCP).1

 Pursuant to the Federal 

 

 1 Under the Board’s Rules of Procedure, an appeal must be filed within 180 days from the date of issuance of an 

OWCP decision. An appeal is considered filed upon receipt by the Clerk of the Appellate Boards. See 20 C.F.R. 

§ 501.3(e)-(f). One hundred and eighty days from OWCP’s December 14, 2015 decision was Saturday, 

June 11, 2016. As the deadline for filing fell on a weekend, it was extended to the next business day, Monday, 

June 13, 2016. 20 C.F.R. § 501.3(f)(2). Because using June 14, 2016, the date the appeal was received by the Clerk 

of the Appellate Boards, would result in the loss of appeal rights, the date of the postmark is considered the date of 

filing. The date of the U.S. Postal Service postmark is June 10, 2016, rendering the appeal timely filed. 20 C.F.R. 

§ 501.3(f)(1). 
2

Employees’ Compensation Act2

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

jurisdiction over the merits of this claim.3

ISSUE 

The issue is whether appellant met her burden of proof to establish an injury causally 

related to the accepted April 30, 2013 employment incident. 

FACTUAL HISTORY 

On May 5, 2015 appellant, then a 50-year-old supervisory biologist, filed a traumatic 

injury claim (Form CA-1) alleging that on April 30, 2013 she received a purified protein 

derivative (PPD) skin test (tuberculosis test) on her left forearm as part of routine occupational 

health testing, which caused a severe reaction on the test site, including erythema, inflammation, 

and swelling. She also alleged that the skin test worsened ongoing pain and inflammation of her 

right shoulder and right arm, which had been caused by an earlier smallpox vaccination on the 

right arm.4

In a May 11, 2015 letter, OWCP advised appellant of the deficiencies in her claim and 

provided her the opportunity to submit additional factual and medical evidence. This included a 

detailed narrative medical report from her treating physician, which contained a history of the 

injury and a medical explanation with objective evidence of how the reported work incident 

caused or aggravated the claimed condition. Appellant was afforded 30 days to submit such 

evidence. 

OWCP received a position description, which indicated that appellant was required to 

receive vaccines because of her exposure to highly infectious agents and toxins, along with 

Notification of Personnel Action (SF-50) forms dated December 16, 2012 and January 11, 2015. 

In a May 20, 2013 report, Dr. Patricia I. Dillon, Chief of the Medical Biosurety Program 

at the Barquist Army Health Clinic, stated that appellant demonstrated hypersensitivity to 

medications after receiving a smallpox immunization in July 2012 that had not completely 

resolved. The immune-triggered inflammatory process tended to occur in the right shoulder area 

involving the joint and overlying muscles. X-rays confirmed that there was an inflammatory 

reaction in the bursa region of the shoulder joint and appellant also continued to experience 

chronic pain. Dr. Dillon reported that on April 30, 2013 a routine PPD was placed on her left 

forearm as part of routine occupational health testing and, 48 hours later, the testing site 

demonstrated a severe reaction with erythema and warmth over the PPD placement site 

extending approximately 4 inches x 2 inches in diameter. By May 16, 2013, the PPD site 

 2

 5 U.S.C. § 8101 et seq. 

3

 Appellant submitted additional evidence with her appeal. The Board’s review is limited to the evidence that 

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

evidence. 20 C.F.R. § 501.2(c)(1). 

4

 Under File No. xxxxxx829, date of injury July 23, 2012, OWCP accepted right brachial plexus neuritis and right 

shoulder myositis due to contact dermitis. 
3

continued to appear inflamed and the left arm was moderately swollen from the wrist to the midhumorous region. In addition, her right shoulder area was experiencing more pain and 

tenderness at both the inner joint and overlying muscular area. Appellant also experienced 

difficulties sleeping as the pain would frequently wake her. Dr. Dillon advised that the working 

diagnosis was that the smallpox vaccination triggered a hypersensitivity immune cascade. She 

opined that the most recent PPD placement introduced an antigen that her immune system 

rejected and exacerbated the inflammatory response at the local site and increased the ongoing 

inflammation at the contralateral shoulder joint. 

In a May 22, 2013 report, Dr. Norman E. Stone, a Board-certified orthopedic surgeon, 

reported that appellant returned for reevaluation of her right shoulder pain after an atypical 

reaction to a smallpox vaccination last summer. He noted that she had made significant progress 

until late April 2013, when she had a left forearm PPD skin test. Dr. Stone reported that it 

subsequently erupted into a significant local soft tissue reaction. Simultaneously, appellant had a 

resurgence of pain in the right shoulder. Dr. Stone reported physical examination findings and 

assessed right shoulder pain, which he opined was likely due to several orthopedic conditions. 

He noted that the flare up of pain after the left forearm PPD skin test was an unclear connection. 

Dr. Stone also assessed left forearm pain after PPD skin test, possibly mild myositis. 

In a May 28, 2014 report, Dr. Wayne O. Wolverton, an internist, noted the history of 

right shoulder pain following her smallpox vaccination. He also noted that appellant recently 

had a PPD skin test and developed local reaction and simultaneous exacerbation of her right 

shoulder pain. Dr. Wolverton noted that testing was negative and while her local reaction has 

subsided over several days, she continued to have right shoulder pain and insomnia due to 

shoulder pain. He provided provisional diagnosis of Type III immune complexes. 

Appellant submitted several reports on June 9, 2015. 

In an August 16, 2013 report, Dr. Stout noted fluid in the subdeloid bursa. An 

immunology study for raised antibody titer was performed, but found no clear etiology. 

Dr. Stout opined that CRPS tissue trauma was a possibility. 

In a September 6, 2013 report, Dr. Brian J. Stout, a Board-certified internist and 

rheumatologist, noted right lateral shoulder pain and left extensor surface arm pain following 

smallpox vaccination to the right shoulder over one year prior and subsequent PPD skin test 

placement on contralateral arm. He opined that overall appellant’s pain pattern appeared most 

consistent with neurologic pain in the arm, possibly a complex regional pain syndrome (CRPS) 

phenomenon. Dr. Stout further opined that appellant’s trapezial pain was most consistent with 

myofascial pain syndrome, likely from protection of the right shoulder. 

In a December 12, 2013 report, Dr. Dillon continued to report on appellant’s condition. 

She indicated that it was not clear which of the contributing factors were the cause of her 

continuing pain and weakness of the right arm: whether it be an overall Type III hypersensitivity 

reaction, a local inflammatory reaction of the right shoulder bursa, damage/inflammation to the 

nerves that supply the shoulder and neck region. 
4

A copy of a Q Sense Test report dated March 12, 2014 and a hand screen test report dated 

March 11, 2014, which indicated muscle weakness in the nerves of the hands, was provided 

along with copies of physical therapy progress notes. 

In a May 24, 2014 report, Dr. Dillon reported on the history of the August 1, 2012 

reaction to the smallpox vaccination and her subsequent reaction to the PPD skin test site. She 

noted that there was some consensus that the PPD skin test triggered underlying immune reaction 

responsible for the chronic brachial plexus neuritis. Over time the neuritis persisted and met the 

criteria for neuralagic amyothrophy (Parsonage-Turner Syndrome). Dr. Dillon noted that the 

source for the underlying nerve disorder initiated by the smallpox vaccine, and then exacerbated 

by the placement of a PPD antigen on the contralateral arm was investigated. She diagnosed 

brachial neuropathy induced by a smallpox vaccination which resulted in severe loss of muscle 

strength and grip in the right hand, which appeared to be permanent in nature. 

By decision dated June 22, 2015, OWCP denied the claim because the factual component 

of fact of injury had not been met. It noted that appellant had not responded to its questionnaire 

and therefore the facts surrounding her claim could not be established. OWCP also noted that 

the medical evidence submitted did not contain a diagnosis. 

On July 22, 2015 OWCP received appellant’s July 20, 2015 request for a representative 

of OWCP’s Branch of Hearings and Review to review the written record. Appellant submitted 

her responses to OWCP’s development questionnaire, medical records from the employing 

establishment’s health unit, and an e-mail indicating that she first notified her employing 

establishment of the injury due to the PPD skin test on May 21, 2013. 

In a July 14, 2015 report, Dr. Dillon reported that on July 23, 2012 appellant was 

immunized with the smallpox vaccination as required by her work and had a serve reaction. It 

presented as a robust local response with a large blister and then whole-body rash. The nerves 

beneath the vaccination site became overactive in the right shoulder/arm area and sent 

continuous messages to the brain. Dr. Dillon noted that a thorough workup by several specialists 

concluded that appellant has CRPS triggered by the local nerve responses to the smallpox 

vaccination. Unfortunately, it has been three years since appellant’s injury from that vaccine and 

to date her symptoms have shown no improvement. Appellant’s syndrome has progressed to the 

point that the right hand and arm have suffered loss of strength objectively documented by 

several clinicians. Dr. Dillon reported that one year following the smallpox vaccination, 

appellant had PPD skin testing required for her position. She noted that, in 2012, appellant had a 

PPD skin test without issue but, one year later, she experienced a robust reaction to the PPD skin 

test. Dr. Dillon indicated that more advanced blood tests were performed and confirmed that 

appellant did not have tuberculosis. She noted that Dr. Jay Montgomery, a Board-certified 

immunologist, had concluded that some component of her immune system must have become 

primed by the smallpox vaccination resulting in the robust PPD response. Dr. Dillon indicated 

that for the first several months following the PPD response on her left arm, appellant 

experienced a sense of “heaviness” and pain over the left arm. Over time, the pain sensation 

reduced, but the sense of “heaviness” persisted. Dr. Dillon stated that it has now been three 

years since the placement of the smallpox vaccination. The pain persists and appellant has 

developed muscle weakness of the right extremity essentially making her right arm 

nonfunctional. Dr. Dillon indicated that those systems were consistent with CRPS. 
5

Furthermore, a recent magnetic resonance imagining (MRI) scan study of the cervical region 

demonstrated hypodense lesions consistent with CRPS. She advised that appellant’s disability 

was permanent and unlikely to resolve. 

By decision dated December 14, 2015, OWCP’s hearing representative modified the 

June 22, 2015 decision to find that the employing establishment had administered the April 30, 

2013 PPD skin test. However, it affirmed the denial of the claim on the basis that the diagnosed 

medical condition of CRPS was not causally related to the April 30, 2013 incident. 

LEGAL PRECEDENT 

A claimant seeking benefits under FECA5 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 that an injury was sustained in the performance of duty as alleged and that 

any specific condition or disability claimed is causally related to the employment injury.6

To determine if 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 in conjunction with one another. 

The first component is whether the employee actually experienced the employment incident that 

allegedly occurred.7 The second component is whether the employment incident caused a 

personal injury.8 An employee may establish that an injury occurred in the performance of duty 

as alleged, but fail to establish that the disability or specific condition for which compensation is 

being claimed is causally related to the injury.9

The fact that a condition manifests itself during a period of employment is not sufficient 

to establish causal relationship.10 Temporal relationship alone will not suffice.11 Entitlement to 

 5 See supra note 2. 

6

 20 C.F.R. § 10.115(e), (f); see Jacquelyn L. Oliver, 48 ECAB 232, 235-36 (1996). 

7 Elaine Pendleton, 40 ECAB 1143 (1989). 

8 John J. Carlone, 41 ECAB 354 (1989). Causal relationship is a medical question that generally requires 

rationalized medical opinion evidence to resolve the issue. Robert G. Morris, 48 ECAB 238 (1996). A physician’s 

opinion on whether there is a causal relationship between the diagnosed condition and the implicated employment 

factor(s) must be based on a complete factual and medical background. Victor J. Woodhams, 41 ECAB 345, 

352 (1989). Additionally, the physician’s opinion must be expressed in terms of a reasonable degree of medical 

certainty, and must be supported by medical rationale, explaining the nature of the relationship between the 

diagnosed condition and appellant’s specific employment factor(s). Id.

9 Shirley A. Temple, 48 ECAB 404, 407 (1997). 

10 20 C.F.R. § 10.115(e). 

11 See D.I., 59 ECAB 158, 162 (2007). 
6

FECA benefits may not be based on surmise, conjecture, speculation, or on the employee’s own 

belief of a causal relationship.12

In any case where a preexisting condition involving the same part of the body is present 

and the issue of causal relationship therefore involves aggravation, acceleration, or precipitation, 

the physician must provide a rationalized medical opinion that differentiates between the effects 

of the work-related injury or disease and the preexisting condition.13

ANALYSIS 

OWCP accepted that the April 30, 2013 PPD vaccination/skin test work incident 

occurred as alleged. It denied appellant’s claim, however, as she had failed to submit 

rationalized medical evidence describing how the accepted incident caused or aggravated any 

medical condition. The record reflects that OWCP had previously accepted several underlying 

conditions, under File No. xxxxxx829, as a result of an adverse reaction to a routine smallpox 

vaccine administered on July 23, 2012.14

The medical reports of record fail to provide a firm diagnosis resulting from the 2013 

PPD vaccination/skin test. Dr. Dillon described appellant’s reaction at the site of the PPD skin 

test (a severe reaction with erythema and warmth over the PPD skin test placement site and later 

inflammation), but failed to diagnose any specific condition resulting therefrom. Dr. Stone 

assessed left forearm pain after PPD skin test, but indicated that the flare up of pain after the left 

forearm PPD skin test was of unclear origin; possible mild myositis. The Board has held that the 

mere diagnosis of “pain” does not constitute the basis for payment of compensation.15 

Additionally, a “possible mild myositis” is not a firm diagnosis of a particular medical 

condition.16 Dr. Wolverton noted that appellant’s reaction to the PPD skin test subsided over 

several days. Thus, no diagnosis was provided from the reaction to the PPD vaccination/skin 

test.17 

 12 See M.H., Docket No. 16-0228 (issued June 8, 2016). 

13 Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3e (January 2013). 

14 See infra note 4. OWCP did not combine the case records prior to adjudicating her claim for the alleged 

April 30, 2013 employment injury and; therefore, the factual and medical evidence pertaining to appellant’s prior 

injury is not fully contained in the case record. As noted, on December 4, 2015 OWCP accepted under claim 

number xxxxxx829, right brachial plexus neuritis and right shoulder myositis. OWCP’s procedures provide that 

cases should be combined when correct adjudication of the issue(s) depends on frequent cross-reference between 

files. Federal (FECA) Procedure Manual, Part 2 -- Claims, File Maintenance & Management, Chapter 2.400.8(c) 

(February 2000). 

15 Robert Broome, 55 ECAB 339 (2004). 

16 See Deborah L. Beatty, 54 ECAB 340 (2003) (where the Board found that, in the absence of a medical report 

providing a diagnosed condition and a reasoned opinion on causal relationship with the employment incident, 

appellant did not meet her burden of proof). 

17 Id. 
7

Dr. Wolverton also provided a provisional diagnosis of Type III immune complexes due 

to the simultaneous exacerbation of her right shoulder pain. However, this is not a firm 

diagnosis and Dr. Wolverton did not provide any opinion on how the April 30, 2013 skin test 

caused or contributed to appellant’s underlying right shoulder pain.18 A medical opinion is 

especially needed in this case as the record reflects that appellant had preexisting right shoulder 

pain stemming from her 2012 smallpox vaccine.19 Accordingly, Dr. Wolverton’s report is of 

limited probative value. 

Dr. Stout opined that appellant’s pain pattern appeared most consistent with neurologic 

pain in the arm, possibly a CRPS phenomenon, and that her trapezial pain was most consistent 

with myofascial pain syndrome, likely from protection of the right shoulder. However, he failed 

to provide an opinion regarding causal relationship and his report is unclear as to which event, he 

was referring the smallpox vaccine administered on July 23, 2012 or the 2013 PPD skin test. 

Lacking a rationalized opinion regarding causal relationship, his report is, therefore, of little 

probative value in establishing appellant’s claim.20

Dr. Dillon provided several reports. In her May 20, 2013 report, she reported that the site 

of the PPD skin test was inflamed and appellant’s left arm was moderately swollen from the 

wrist to the mid-humorous region. However, as noted earlier, no diagnosis was provided in 

relation to the PPD skin test.21 Dr. Dillon also reported that the right shoulder area was 

experiencing more pain and tenderness at both the inner joint and overlying muscular area and 

the working diagnosis was that the smallpox vaccination triggered a hypersensitivity immune 

cascade. She opined that the most recent PPD skin test introduced an antigen that her immune 

system rejected which exacerbated the inflammatory response at the local site and increased the 

ongoing inflammation at the contralateral shoulder joint. Dr. Dillon, however, failed to provide 

any medical rationale as to how the PPD placement exacerbated appellant’s preexisting 

inflammatory response and increased the ongoing inflammation at the contralateral shoulder 

joint.22 As noted, a medical opinion is especially needed in the case as the record reflects that 

appellant had a preexisting chronic pain and shoulder problems at the contralateral shoulder 

joint.23 

In a May 24, 2014 report, Dr. Dillon indicated that appellant has neuralagic amyothrophy 

(Parsonage-Turner Syndrome) which resulted in severe loss of muscle strength and grip in the 

right hand, which appeared permanent in nature. She stated that the source for the underlying 

nerve disorder was inducted by the smallpox vaccine and then exacerbated by the placement of a 

PPD antigen on the contralateral arm. However, Dr. Dillon again failed to provide any medical 

 18 Id. 

19 See B.T., Docket No. 13-138 (issued March 20, 2013). 

20 See A.M., Docket No. 14-1399 (issued September 23, 2014). 

21 Supra note 16. 

22 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, supra note 8. 

23 See B.T., supra note 19. 
8

rationale as to how the PPD placement exacerbated the underlying nerve disorder. Thus, this 

report is of limited probative value.24

In her July 14, 2015 report, Dr. Dillon opined that appellant had CRPS and that the 

limitations of her right arm were permanent. She indicated that, following the PPD response on 

her left arm, appellant experienced a sense of “heaviness” and pain over the left arm. Over time, 

the pain sensation reduced, but the sense of “heaviness” persisted. Dr. Dillon stated that three 

years have passed since the placement of the smallpox vaccination and the pain persists and 

appellant has developed muscle weakness of the right extremity essentially making her right arm 

nonfunctional. She indicated that those systems were consistent with CRPS and noted that a 

recent MRI scan of the cervical region demonstrated hypodense lesions consistent with CRPS. 

This diagnosis, however, relates to the earlier smallpox vaccination on the right arm. While 

Dr. Dillon indicated the sense of “heaviness” persisted on the left arm following the PPD test, 

she has offered no diagnosis in connection with the PPD skin test.25 Additionally, while she 

opined that appellant has CRPS and the limitations of the right arm were permanent, Dr. Dillon 

has not explained how or whether the PPD skin test merely worsened the symptoms of the 

already developing CRPS or contributed to its development. Stated differently, she has not 

explained whether and how the PPD skin test changed the course of the inflammatory response, 

which she indicated was already present due to the smallpox vaccine. Thus, this report is 

insufficient to establish causal relationship.26 

The additional medical evidence is of limited probative value. The medical testing of 

record failed to offer a medical opinion as to how the reported work incident caused or 

aggravated a medical condition. The Board has held that medical evidence which does not offer 

any opinion regarding the cause of an employee’s condition is of limited probative value on the 

issue of causal relationship.27 Thus, these reports are insufficient to establish appellant’s claim. 

Causal relationship is a medical question that must be established by probative medical 

opinion from a physician.28 In this case, the Board finds that none of the medical evidence 

constitutes rationalized medical evidence, based upon a specific and accurate history of 

employment conditions, which are alleged to have caused or exacerbated her preexisting medical 

condition.29 Accordingly, the Board finds that, while appellant has established incident, she has 

failed to meet her burden of proof to establish a causal relationship between the work incident 

and her diagnosed conditions. Neither the fact that a disease or condition manifests itself during 

 24 See Michael E. Smith, 50 ECAB 313 (1999). 

25 See Deborah L. Beatty, supra note 16. 

26 See Michael E. Smith, supra note 23. 

27 L.M., Docket No. 16-0188 (issued March 24, 2016); Jaja K. Asaramo, 55 ECAB 200 (2004). 

28 W.W., Docket No. 09-1619 (issued June 2, 2010); David Apgar, 57 ECAB 137 (2005). 

29 Patricia J. Bolleter, 40 ECAB 373 (1988). 
9

a period of employment nor the belief that the disease or condition was caused or aggravated by 

the employment factors or incident is sufficient to establish causal relationship.30

On appeal appellant contends that the medical reports support the causal relationship 

between the April 30, 2013 employment incident and her diagnosed conditions. However, as 

explained above, the medical evidence is insufficient to establish a medical diagnosis for the 

accepted employment incident and fails to explain how or whether the PPD skin test merely 

worsened the symptoms of the already developing CRPS or contributed to its development. 

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 failed to meet her burden of proof to establish an injury 

causally related to the accepted April 30, 2013 employment incident. 

ORDER 

IT IS HEREBY ORDERED THAT the December 14, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: September 27, 2017 

Washington, DC 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board 

 30 See Dennis M. Mascarenas, 49 ECAB 215 (1997).