United States Department of Labor 

Employees’ Compensation Appeals Board 

_________________________________________ 

C.R., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Media, PA, Employer 

___________________________________________

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Docket No. 16-0126 

Issued: May 18, 2016 

Appearances: Case Submitted on the Record 

Thomas R. Uliase, Esq., for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

COLLEEN DUFFY KIKO, Judge 

ALEC J. KOROMILAS, Alternate Judge 

JURISDICTION 

On October 29, 2015 appellant, through counsel, filed a timely appeal of a May 21, 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 traumatic injury in 

the performance of duty on December 11, 2013. 

FACTUAL HISTORY 

On December 11, 2013 appellant, then a 31-year-old city carrier, filed a traumatic injury 

claim (Form CA-1) alleging that on that date she fell while getting out of her truck in the 

 1

 5 U.S.C. § 8101 et seq.
2

performance of duty. She indicated that she injured her lower back and had pain shooting down 

the right leg. Appellant stopped work on that date. 

In a December 11, 2013 statement, appellant stated that she was wearing ice and snow 

cleats, and properly exited the truck. She explained that as soon as she had both feet placed on 

the ground, she slipped as she turned around to walk to the mailbox. Appellant noted that she 

tried to catch herself, but her feet flew up from under her and she fell on her buttocks and back. 

She did not feel any pain while she finished her collections. However, two hours later, appellant 

was unable to bend over without being in pain. 

OWCP received a December 11, 2013 emergency department note from Riddle Hospital 

excusing appellant from work and a (Form CA-17) duty status report also dated December 11, 

2013 from a nurse practitioner. 

In a letter dated January 9, 2014, OWCP noted that appellant’s claim initially appeared to 

be a minor injury that resulted in minimal or no lost time from work and her claim had been 

administratively handled to allow a limited amount of medical payments, but that it was now 

developing the claim. It note that medical evidence from a nurse practitioner was insufficient 

and requested a physician’s opinion explaining how the reported work incident caused or 

contributed to her condition. OWCP informed appellant of the type of evidence needed to 

support her claim and afforded her 30 days to submit such evidence. Appellant did not respond 

to the request. 

OWCP received January 16, and 23, 2014 work status reports from appellant’s health 

care provider which diagnosed lower back sprain. These reports either had no signature or an 

illegible signature of the health care provider. 

By decision dated February 10, 2014, OWCP denied appellant’s claim as she had not 

established an injury as alleged. It found that the medical evidence failed to demonstrate a 

diagnosed medical condition causally related to the accepted work-related incident. 

On March 5, 2014 counsel requested a hearing, which was held on June 9, 2014. 

Appellant submitted an employee rights and responsibility traumatic injury form and physical 

therapy reports. 

In a letter dated July 1, 2014, counsel provided additional medical evidence. In a 

June 25, 2014 report, Dr. Menachem M. Meller, a Board-certified orthopedic surgeon, noted that 

he had seen appellant on February 11 and 25, March 13, and April 1, 2014. He advised that 

during her treatment she presented primarily with axial back pain at the belt line and at the 

posterior superior iliac spine. Dr. Meller explained that there was no bladder or bowel 

dysfunction, no verifiable neurologic deficits, and a presence of behavioral confounders. He 

read the results of a magnetic resonance imaging (MRI) scan which was taken on 

February 19, 2014. It revealed severe degenerative disc disease at L5-S1 with disc extrusion, 

herniated disc material contacting the traversing S1 nerve roots, and moderate right foraminal 

narrowing with displacement of the exiting L5 nerve root. 

Dr. Meller noted that appellant had physical therapy on January 6, 2014 and was being 

released for full-time work with permanent restrictions. He summarized that she had a slip and 
3

fall on ice landing on her back and was found to have a significant amount of preexisting 

degeneration as well as a herniated disc at L5-S1 that was contacting or abutting on the 

traversing S1 nerve root and displacing the exiting L5 nerve root. Dr. Meller found that 

appellant had not reached maximum medical improvement and was referred to neurology as he 

believed that she might benefit from surgical decompression and possibly a fusion. 

By decision dated July 28, 2014, an OWCP hearing representative affirmed the 

February 10, 2014 decision. She found that there was no medical evidence discussing how any 

specific diagnosis related to a fall on ice at work. 

On February 24, 2015 counsel requested reconsideration. He provided new medical 

evidence and argued that appellant had submitted sufficient medical evidence to establish causal 

relationship between the diagnosed conditions and her accepted work incident. 

In a February 17, 2105 report, Dr. Steven Valentino, an osteopath and a Board-certified 

orthopedic surgeon, noted that appellant presented with low back pain localized from L3 through 

S1 with radiation into both legs with numbness. He advised that her symptoms were apportioned 

to the work injury which occurred on December 11, 2013. Dr. Valentino noted that appellant 

slipped on ice while at work as letter carrier. He advised that lumbar decompression surgery was 

recommended but denied. Dr. Valentino explained that appellant had a prior work injury in 

2001, while working as a ramp agent for an airline where she had sustained an L5-S1 disc 

herniation. He indicated that the injury was treated with chiropractic care with improvement 

such that she had returned to a full-time position. Dr. Valentino advised that the MRI scan 

performed on February 19, 2014 revealed severe degenerative disc disease at L5-S1 with disc 

extrusion, with herniated disc material contacting the traversing S1 nerve roots. He opined that 

“[c]learly this accident caused an aggravation of her prior L5-S1 disc herniation along with 

aggravation of underlying degenerative disc disease and sciatica.” Dr. Valentino stated that his 

opinion was made within a reasonable degree of medical certainty. He noted that his opinion 

was based on positive objective findings on physical examination, positive MRI scan, and the 

fact that appellant had recovered from her prior 2001 injury and had returned to work full time 

without any symptoms or impairment until the December 11, 2013 incident. 

OWCP also received physical therapy reports which were submitted by counsel in 

support of the claim. 

In a May 21, 2015 decision, OWCP denied modification of the prior decision. It noted 

that Dr. Valentino’s opinion was based on appellant’s reported history and was summarized in 

general terms. OWCP also noted that appellant had not provided a history as requested in the 

initial development letter of January 9, 2014. It found that Dr. Valentino failed to provide an 

objective basis for his diagnosis apart from the findings from the MRI scan, but those noted 

findings were consistent with the preexisting injury. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA has 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 
4

applicable time limitation period of FECA,2

 and that an injury was sustained in the performance 

of duty.3

 These are the essential elements of each compensation claim regardless of whether the 

claim is predicated upon a traumatic injury or an occupational disease.4

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether the fact of injury has been established. 

There are two components involved in establishing the 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.5 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.6 

Rationalized medical opinion evidence is generally required to establish causal 

relationship. The opinion of the physician must be based on a complete factual and medical 

background, 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.7

ANALYSIS 

Appellant alleged that on December 11, 2013 she sustained an injury to her lower back 

with pain shooting down her right leg after she fell while exiting her delivery truck in the 

performance of duty. OWCP accepted that the claimed event occurred as alleged. 

However, the medical evidence is insufficiently rationalized to establish that the accepted 

employment incident caused an injury. The medical evidence does not contain a sufficiently 

reasoned explanation of how the specific employment incident, which occurred on December 11, 

2013, caused or aggravated an injury.8 The Board notes that this is particularly important in light 

of the prior injury in 2001 in which appellant sustained an L5-S1 disc herniation. The record 

also reflects that appellant had preexisting degenerative low back conditions. 

Appellant submitted a June 25, 2014 report from Dr. Meller who noted axial back pain at 

the belt line and posterior superior iliac spine. He indicated that the MRI scan of February 19, 

2014 revealed severe degenerative disc disease at L5-S1 with disc extrusion, herniated disc 

 2 Joe D. Cameron, 41 ECAB 153 (1989). 

3 James E. Chadden, Sr., 40 ECAB 312 (1988). 

4 Delores C. Ellyett, 41 ECAB 992 (1990). 

5 Julie B. Hawkins, 38 ECAB 393, 396 (1987); see Federal (FECA) Procedure Manual, Part 2 -- Claims, Fact of 

Injury, Chapter 2.803.2a (June 1995). 

6 Id. For a definition of the term “traumatic injury,” see 20 C.F.R. § 10.5(ee). 

7 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 

8 See George Randolph Taylor, 6 ECAB 986, 988 (1954) (where the Board found that a medical opinion not 

fortified by medical rationale is of little probative value). 
5

material contacting the traversing S1 nerve roots, and moderate right foraminal narrowing with 

displacement of the exiting L5 nerve root. Dr. Meller explained that appellant had a slip and fall 

on ice, landed on her back, and also had a significant amount of preexisting degeneration as well 

as a herniated disc at L5-S1 contacting or abutting on the traversing S1 nerve root and displacing 

the exiting L5 nerve root. He determined that her restrictions were permanent and that she had 

not reached maximum medical improvement. This report is of limited probative value as 

Dr. Meller did not provide a clear opinion on causal relationship.9

 To the extent that his 

statement of the history of appellant having a slip and fall on ice may be construed as supporting 

causal relationship, he did not provide medical rationale explaining how this incident caused or 

contributed to the diagnosed condition. 

In a February 17, 2015 report, Dr. Valentino noted that appellant presented with low back 

pain localized from L3 through S1 with radiation into the bilateral legs with numbness. He noted 

that on December 11, 2013 she slipped on ice while at work and opined that her symptoms were 

due to the work injury. Dr. Valentino explained that appellant had a prior work injury in 2001 in 

which she had sustained an L5-S1 disc herniation. He advised that she was treated with 

chiropractic care at that time with improvement such that she returned to full-time employment. 

Dr. Valentino reviewed the MRI scan from February 19, 2014. He opined, within a reasonable 

degree of medical certainty, that “[c]learly this accident caused an aggravation of her prior L5-S1 

disc herniation along with aggravation of underlying degenerative disc disease and sciatica.” 

Dr. Valentino explained that his opinion was based upon positive objective findings on physical 

examination, the positive MRI scan, and the fact that appellant had recovered from her prior 

2001 injury and had returned to work full time without any symptomatology or impairment until 

the December 11, 2013 incident. However, a medical opinion that states that a condition is 

causally related to an employment injury because the employee was asymptomatic before the 

injury but symptomatic after the injury is insufficient, without supporting rationale, to establish 

causal relationship.10 Furthermore, other than to review the MRI scan, Dr. Valentino did not 

provide objective findings to explain how he arrived at his conclusion.11 He did not explain how 

the MRI scan findings were supportive of a new injury. The need for detailed rationale is 

particularly important in view of appellant’s 2001 history of an L5-S1 disc herniation. Thus, 

Dr. Valentino’s report is of limited probative value. 

Diagnostic and other medical reports are insufficient to establish the claim as these 

reports do not address how employment factors contributed to a diagnosed medical condition.12

 9 See Charles H. Tomaszewski, 39 ECAB 461, 467-68 (1988) (finding 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). 

10 T.M., Docket No. 08-975 (issued February 6, 2009). 

11 Rationalized medical opinion evidence is medical evidence, which includes a physician’s opinion on the issue 

of whether there is a causal relationship between the claimant’s diagnosed condition and the implicated employment 

factor(s). 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. Gloria J. McPherson, 51 ECAB 441 (2000). 

12 See supra note 9. 
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OWCP received nurses’ notes and physical therapy reports in support of appellant’s 

claim. However, section 8101(2) of FECA provides that the term physician includes surgeons, 

podiatrist, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic 

practitioners within the scope of their practice as defined by State law.13 Nurses are not 

considered physicians under FECA and are not competent to render a medical opinion.14 

Likewise, physical therapists are not considered physicians under FECA and thus their reports 

also do not constitute competent medical evidence.15 The record also contains unsigned reports 

or reports with an illegible signature. However, reports lacking proper identification do not 

constitute probative medical evidence.16 Consequently, these reports are insufficient to establish 

clear error by OWCP. 

Because the medical evidences submitted by appellant do not sufficiently address how 

the December 11, 2013 activities at work caused or aggravated a low back condition, these 

reports are of limited probative value17 and are insufficient to establish that the December 11, 

2013 employment incident caused or aggravated a specific injury. 

On appeal, counsel for appellant argues that the report of Dr. Valentino warranted further 

development by OWCP. However, as previously explained above, the evidence was insufficient 

to establish causal relationship. 

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 traumatic 

injury in the performance of duty on December 11, 2013. 

 13 5 U.S.C. § 8101(2). 

14 G.G., 58 ECAB 389 (2007). 

15 J.M., 58 ECAB 448 (2007); id.; David P. Sawchuck, 57 ECAB 316 (2006); Allen C. Hundley, 53 ECAB 

551 (2002). 

16 See C.B., Docket No. 09-2027 (issued May 12, 2010) (a medical report may not be considered as probative 

medical evidence if there is no indication that the person completing the report qualifies as a physician as defined in 

5 U.S.C. § 8101(2). 

17 See Linda I Sprague, 48 ECAB 386, 389-90 (1997). 
7

ORDER 

IT IS HEREBY ORDERED THAT the May 21, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: May 18, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board