United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

A.B., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Edison, NJ, Employer 

__________________________________________ 

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Docket No. 16-0556 

Issued: June 23, 2016 

Appearances: Case Submitted on the Record

James D. Muirhead, Esq., for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

COLLEEN DUFFY KIKO, Judge 

ALEC J. KOROMILAS, Alternate Judge 

JURISDICTION 

On February 3, 2016 appellant, through counsel, filed a timely appeal from a 

September 9, 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 an injury causally 

related to the September 12, 2012 employment incident. 

FACTUAL HISTORY 

On September 12, 2012 appellant, then a 56-year-old mail handler, filed a traumatic 

injury claim (Form CA-1) alleging that, on that same date, she pulled hard to unplug a cord from 

a forklift battery which caused her to fall back and hit her back against a beam. She stated that 

 1

 5 U.S.C. § 8101 et seq.
2

she had to get assistance from coworker Sharell McKnight. Appellant notified her supervisor of 

the incident on the date of injury. She stopped work and first received medical care on 

September 13, 2012. 

The employing establishment issued appellant a properly completed Form CA-16, 

authorization for examination, dated September 12, 2012, which indicated that appellant was 

authorized to seek medical treatment for a strain of the lower back related to the September 12, 

2012 employment incident at Christ Hospital, Pallisades Avenue, Jersey City, NJ 07306. 

In an accompanying attending physician’s report (Form CA-20) dated September 13, 

2012, Dr. Valdi Sapira, Board-certified in internal medicine, reported that appellant fell and hit a 

beam at work on September 12, 2012. He diagnosed back injury. Christ Hospital discharge 

notes were submitted along with a September 13, 2012 duty status report (Form CA-17) advising 

appellant that she could resume work on September 14, 2012. 

Dr. Alexander G. Salerno, Board-certified in internal medicine, in a September 24, 2012 

prescription note, recommended physical therapy for appellant’s back and shoulders. 

By report dated October 2, 2012, Dr. Howard Kessler, a Board-certified radiologist, 

related that a magnetic resonance imaging (MRI) scan of the thoracic spine revealed left 

paracentral disc herniation at T7-8 with mild thecal sac indentation, multiple mild 

noncompressive disc bulges at T4-5, T5-6, and T6-7, hemangioma at T9, and no intrinsic cord 

abnormality or foraminal encroachment. 

On October 23, 2012 OWCP notified appellant that the evidence of record was 

insufficient to support her claim. Appellant was advised of the medical and factual evidence 

needed and was afforded 30 days to respond. 

In support of her claim, appellant submitted physical therapy notes dated October 15 

through November 12, 2012 documenting treatment for her back. Return to work notes dated 

September 24 through October 23, 2012 were also submitted for a back injury. 

On November 26, 2012 OWCP received additional medical documentation. In forms 

dated September 13 and 24, 2012, Dr. Salerno diagnosed back sprain. In a November 1, 2012 

prescription note, he recommended an MRI scan of the left shoulder noting the diagnosis as 

rotator cuff. On November 9, 2012 Dr. Salerno completed a Form CA-20 in which he related 

that appellant had fallen three feet backwards and landed on a beam. He diagnosed disc disease 

based on an MRI scan of the thoracic spine and noted no history of preexisting injury. 

Dr. Salerno checked the box marked “yes” when asked if the condition was caused or aggravated 

by the employment activity described. 

By decision dated November 29, 2012, OWCP denied appellant’s claim, finding that the 

evidence of record failed to establish that her degenerative disc disease was causally related to 

the accepted September 12, 2012 employment incident. 

On December 12, 2012 appellant, through counsel, requested a telephone hearing before 

an OWCP hearing representative. 
3

In support of her claim, appellant submitted physical therapy notes dated November 14 

through December 28, 2012. 

On January 2, 2013 Dr. Daniel B. Lerer, a Board-certified diagnostic radiologist, reported 

that an MRI scan of the left shoulder revealed mild diffuse rotation cuff tendinitis with no rotator 

cuff tendon tear; mild subacromial/subdeltoid bursitis with no appreciable impingement; and 

moderate size glenohumeral ligament with findings suspicious for a SLAP tear. 

By letter dated February 28, 2013, counsel for appellant resubmitted Dr. Salerno’s 

September 24, 2012 physical therapy prescription as well a newly submitted February 19, 2013 

report from Dr. Richard A. Boiardo, a Board-certified orthopedic surgeon. 

In his February 19, 2013 narrative report, Dr. Boiardo explained that he initially 

evaluated appellant on December 21, 2012 who complained of pain and restricted motion in the 

low back, thoracic spine, and left shoulder. He noted past medical and surgical history was 

noncontributory. Dr. Boiardo explained that appellant sustained a fall at work on September 12, 

2012 when she landed on her buttocks and back and injured the left shoulder and thoracic spine. 

He provided findings on physical examination and reviewed diagnostic studies. Dr. Boiardo 

noted that an MRI scan of the left shoulder revealed rotator cuff tendinosis, SLAP tear of the 

glenoid labrum, and evidence of subacromial and subdeltoid bursitis. 

An October 2, 2012 MRI scan of the thoracic spine revealed left paracentral disc 

herniation at T7-8 with mild thecal sac indentation as well as noncompressive disc bulge at T4-5, 

T5-6, and T6-7. Dr. Boiardo opined that as a direct and causal result of the slip and fall injury 

appellant sustained in September 2012, she would require arthroscopic surgery to the shoulder 

including decompression and labral repair, as well as likely surgery for the thoracic spine if 

conservative management fails. He explained that the traumatic episode clearly supported 

trauma to the lumbar and thoracic spinal units. Dr. Boiardo noted that the magnitude of injury 

and the mechanism of injury, including the torsional aspect of the fall, was enough to herniate a 

disc, and specifically in this instance, the cause of the disc herniation at T7-8. He further stated 

that appellant’s injury was a disc herniation and not degenerative disc disease as alluded to in 

OWCP’s decision. Dr. Boiardo opined that the mechanism of injury would also explain the 

increased force to the shoulder with an element of torsional which was the mechanism of injury 

for the labral tear. He concluded that appellant’s injuries and necessary surgeries were a direct 

and causal result of the September 2012 injury. Return to work notes dated December 27, 2012 

through February 17, 2013 were submitted. 

A hearing was held on March 5, 2013. At the hearing appellant described the 

employment incident, stating that when she was attempting to unplug the cord from the forklift 

she went backwards, hitting her mid back on a beam three feet away, causing her to fall to the 

floor. She sought emergency treatment that same date due to pain in her low back. Following 

her hospital visit, appellant felt pain in her back as well as her shoulder. She notified her treating 

physician Dr. Salerno who submitted her for an MRI scan. 

By decision dated April 19, 2013, the OWCP hearing representative affirmed the 

March 5, 2013 decision, finding that the evidence of record failed to establish that her diagnosed 

conditions were causally related to the September 12, 2012 employment incident. It noted that 
4

appellant alleged that she struck a table leg and fell backwards which was contradicted by 

Dr. Boiardo’s report who stated that she fell on her buttocks. 

By letter dated June 20, 2013, appellant, through counsel, requested reconsideration of 

OWCP’s decision. 

In a May 6, 2013 narrative statement, appellant provided clarification regarding her 

injury stating that on September 12, 2012 she was pulling on a forklift battery cable and fell 

backwards. She struck her middle back on a steel table leg and then fell to the ground landing on 

her buttocks. Appellant reported that her supervisor, Joe Pelle, had to help her get up from the 

floor. 

By decision dated September 20, 2013, OWCP denied modification of the April 19, 2013 

decision, finding that appellant failed to establish that her diagnosed conditions were causally 

related to the alleged employment incident. It noted that her statement was contradictory as it 

was unclear if her supervisor had to help her off the floor. 

By letter dated October 23, 2013, appellant, through counsel, requested reconsideration 

of the prior OWCP decision. Appellant submitted an October 6, 2013 narrative statement 

explaining in detail the September 12, 2012 employment incident and the witnesses present. She 

noted that Mr. Pelle was unable to submit a statement as he took leave beginning the week of 

September 12, 2012 and had not returned. Appellant further noted that coworker, 

Ms. McKnight, witnessed the employment incident. 

By decision dated February 12, 2014, OWCP denied modification finding that the 

evidence of record failed to establish that her diagnosed conditions were causally related to the 

alleged employment incident. It noted that appellant’s statements were contradictory as she 

reported falling back and striking a table leg while Dr. Boiardo noted a history of falling on her 

buttocks. 

On March 24, 2014 appellant, through counsel, requested reconsideration of OWCP’s 

decision. Counsel argued that an accompanying USPS accident report established that appellant 

was unplugging a tightly connected battery cable from the forklift, pulled hard, and fell 

backwards into the floor beam. The report indicated that appellant was harmed by beam and 

floor and fell to the floor, substantiating appellant’s claim that she fell backwards into the table 

leg then floor. 

In a September 13, 2012 USPS accident report, the history of incident was described as, 

“Employee stated that when she was unplugging the battery cable to the forklift, the connection 

was tight, and she pulled hard fell backwards into the floor beam.” The report further stated that 

the object or substance directly harming the employee was “beam and floor” and described the 

cause/circumstance as “falls to floor.” 

By letter dated April 21, 2014, counsel for appellant resubmitted the September 12, 2012 

Form CA-1 to establish that the incident occurred in the manner alleged. He also submitted a 

September 13, 2012 statement from Ms. McKnight who affirmed appellant’s description of the 

employment incident. 
5

By decision dated June 17, 2014, OWCP’s modification of its prior decision, found that 

the evidence of record failed to establish that her diagnosed conditions were causally related to 

the accepted September 12, 2012 employment incident. It noted that contrary to the April 19, 

2013 decision of the Branch of Hearings and Review, the factual evidence established that 

appellant fell backwards onto a beam/table leg and then fell down to the floor on her buttocks as 

she was unplugging the battery cable attached to the forklift. 

By letter dated June 12, 2015, appellant, through counsel, requested reconsideration of 

OWCP’s decision. Counsel noted submission of a June 12, 2015 supplemental report from 

Dr. Boiardo as an addendum to his prior February 13, 2013 report in support of appellant’s 

claim. 

In a June 12, 2015 medical report, Dr. Boiardo noted that he last examined appellant on 

June 8, 2014, having again discussed the mechanism of injury and her progress. Based on his 

June 8, 2014 examination, he diagnosed herniated disc in the thoracic spine and having 

undergone left shoulder arthroscopically. Dr. Boiardo described the mechanism of injury as told 

to him by appellant, stating that appellant was trying to unplug a cord from the battery cable 

which was attached to the forklift. Appellant asked one of her coworkers to assist her and as she 

pulled on one side, the coworker pulled on the other side. At that point she went backwards, fell 

backwards, landed on the beam, and went to the floor. 

Dr. Boiardo noted that appellant sustained direct trauma to the back, with an implication 

that there was an element of twisting since she was pulling, fell directly back on a beam, and also 

injured her left shoulder. He explained that the direct force of appellant falling backwards was 

anchored in a certain way by her left upper extremity. Dr. Boiardo reported that appellant fell, 

and during the course of falling, sustained trauma to the left shoulder and to the low back. He 

referenced a torsional injury with respect to the back explaining that as one falls and hits a direct 

object, especially holding on to a cable, there has to be a torsional element to the injury. 

Dr. Boiardo reported that appellant sustained a labral tear to the left shoulder, either by the direct 

force of her continued grasp of the cable with her bodyweight pulling against, sustaining a sharp 

trauma when she struck the table leg. He referenced the February 19, 2013 report for the 

remainder of the signs and symptoms and treatment course. 

Dr. Boiardo further reported that the exact nature of the traumatic injury to the thoracic 

spine and left shoulder was clearly defined in appellant’s testimony which he had the opportunity 

to review. He reiterated that appellant was holding onto a forklift battery cable with the left 

upper extremity, having sustained a fall sustaining direct trauma to the steel beam or table leg. 

Dr. Boiardo explained that unless the steel beam was to impale appellant directly, she had to 

torsionally twist the upper thoracic spine, as well as continue to hold on to the cable as she did. 

As such, the force of her body weight while holding on to the cable was enough to possibly 

sublux the shoulder or at least injure the labrum, causing a separation/tear which was the 

pathological finding at surgery. Dr. Boiardo opined that as a direct result of the forklift injury 

and the September 12, 2012 accident, appellant injured the thoracic spine sustaining a herniated 

thoracic disc at T7-8 and injury to the left shoulder while holding on to the battery cable, 

sustaining a labral tear which required arthroscopic surgery. He concluded that appellant 

remained partially permanently disabled. 
6

By decision dated September 9, 2015, OWCP denied modification of its prior decision, 

finding that the evidence of record failed to establish that appellant’s diagnosed conditions were 

causally related to the accepted September 12, 2012 employment incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA has the burden of establishing 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 filed within the applicable time 

limitation, that an injury was sustained while in the performance of duty as alleged, and that any 

disability or specific condition for which compensation is claimed are causally related to the 

employment injury.2 These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated on a traumatic injury or occupational disease.3

In order to determine whether an employee actually sustained an 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 which must be considered in 

conjunction with one another. The first component to be established is that the employee 

actually experienced the employment incident which is alleged to have occurred.4

 The second 

component is whether the employment incident caused a personal injury and generally can be 

established only by medical evidence. 

To establish causal relationship between the condition, as well as any attendant disability 

claimed and the employment event or incident, the employee must submit rationalized medical 

opinion evidence supporting such a causal relationship.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 claimant. This medical opinion must include an accurate history of the employee’s 

employment injury and must explain how the condition is related to the injury. The weight of 

medical evidence is determined by its reliability, its probative value, its convincing quality, the 

care of analysis manifested, and the medical rationale expressed in support of the physician’s 

opinion.6

ANALYSIS 

OWCP accepted that the September 12, 2012 employment incident occurred as alleged.

The issue is whether appellant established that the incident caused her a thoracic spine and left 

 2 Gary J. Watling, 52 ECAB 278 (2001); Elaine Pendleton, 40 ECAB 1143, 1154 (1989). 

3 Michael E. Smith, 50 ECAB 313 (1999). 

4 Elaine Pendleton, supra note 2. 

5 See 20 C.F.R. § 10.110(a); John M. Tornello, 35 ECAB 234 (1983). 

6 James Mack, 43 ECAB 321 (1991). 
7

shoulder injury. The Board finds that she did not submit sufficient medical evidence to support 

that her thoracic disc herniation at T7-8 and a labral tear of the left shoulder are causally related 

to the September 12, 2012 employment incident.7 

In medical reports dated February 19, 2013 and June 12, 2015, Dr. Boiardo diagnosed 

thoracic disc herniation at T7-8 and a labral tear of the left shoulder which he opined was 

causally related to the September 12, 2012 employment incident. He described the traumatic 

incident as related to him by appellant when she was trying to unplug a cord from a battery cable 

attached to a forklift. Appellant pulled on one side of the cord as a coworker pulled on the other 

side and at that point, she fell backwards, landed on a beam, and then down to the floor. 

Dr. Boiardo noted that she sustained a direct trauma to the back with the implication that there 

was an element of twisting since she was pulling, fell directly back on the beam, and also injured 

her left shoulder. He explained that the traumatic episode clearly supported trauma to the lumbar 

and thoracic spinal units. Dr. Boiardo noted that the magnitude of injury and the mechanism of 

injury, including the torsional aspect of the fall, was enough to cause a herniated disc, and 

specifically in this instance, the cause of the disc herniation at T7-8. He further reported that 

appellant’s left shoulder labral tear was caused by holding on to the battery cable. 

The Boards finds that Dr. Boiardo’s opinion is insufficiently rationalized. While the 

physician diagnosed thoracic disc herniation at T7-8, he failed to provide a sufficient explanation 

as to the cause of this injury. Dr. Boiardo’s opinion on causal relationship did not adequately 

explain how the September 12, 2012 employment incident caused or aggravated her disc 

herniation other than generally noting the magnitude and mechanism of injury, including the 

torsional aspect of the fall, was enough to cause a herniated disc. His statement on causation 

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

injury claim, namely, appellant’s backwards fall landing on her buttocks, would cause or 

aggravate appellant’s disc herniation.8

 

Dr. Boiardo’s statement on causation pertaining to the left shoulder tear is also 

insufficient to establish appellant’s claim. His June 12, 2015 report noted that during the course 

of falling, she sustained trauma to the left shoulder and back. However, Dr. Boiardo’s narrative 

contradicts appellant’s statement as she made no allegations of left shoulder contact when 

falling. Nor did appellant complain of left shoulder pain or injury when seeking emergency 

medical treatment on September 12, 2012. Dr. Boiardo’s further stated that, “The patient was 

falling, fell backwards, and went down on the floor. At that point, the patient sustained direct 

trauma to the back, but again the implication is that there is an element of twisting since the 

patient was pulling, fell directly back on a beam, and the patient also injured her left shoulder.” 

Dr. Boiardo’s description of movements made during the September 12, 2012 employment 

incident is speculative and unfounded by appellant’s own allegations as she never described 

tortional twisting. Moreover, his opinion on causation is unfounded as he is describing physical 

motions and movements to fit the left shoulder injury, but which were not based on her injury 

claim. Dr. Boiardo further stated that appellant sustained a labral tear of the left shoulder by the 

force of her body weight while holding on to the cable. Not only does this opinion vary from his 

 7 See Robert Broome, 55 ECAB 339 (2004). 

8 S.W., Docket 08-2538 (issued May 21, 2009). 
8

prior assertion that she sustained trauma to the left shoulder during the course of falling, he also 

failed to provide a detailed description of how holding a cable with the force of her body weight 

would cause a tear in the left shoulder. Medical reports without adequate rationale on causal 

relationship are of diminished probative value and do not meet an employee’s burden of proof.9

 

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 or factor of employment.10 Without explaining 

how physiologically the movements involved in the employment incident caused or contributed 

to the diagnosed conditions, Dr. Boiardo’s opinion on causal relationship is equivocal in nature 

and of limited probative value.11 

Appellant also submitted medical notes and forms dated September 12 through 

November 9, 2012 from Dr. Salerno. While Dr. Salerno’s September 12 and 24, 2012 reports 

noted a diagnosis of back sprain, he provided no opinion as to the cause of this injury. The 

Board has held that medical evidence that does not offer any opinion regarding the cause of an 

employee’s condition is of limited probative value.12 Dr. Salerno’s November 9, 2012 attending 

physician’s report is also insufficient to support appellant’s claim. He diagnosed disc disease 

based on an MRI scan of the thoracic spine. However, Dr. Salerno’s diagnosis is not supported 

by the objective evidence of record as Dr. Kerrer’s October 2, 2012 MRI scan of the thoracic 

spine did not show evidence of disc disease. He checked the box marked “yes” when asked if 

the condition was caused or aggravated by the employment activity. The Board has held that a 

report that addresses causal relationship with a checkmark, without medical rationale explaining 

how the work condition caused the alleged injury, is of diminished probative value and 

insufficient to establish causal relationship.13 Thus, Dr. Salerno’s reports are insufficient to meet 

appellant’s burden of proof. 

The remaining medical evidence is also insufficient to establish causal relationship 

between appellant’s injury and the September 12, 2012 employment incident. While Dr. Kessler 

and Dr. Lerer’s diagnostic reports provided findings pertaining to the thoracic spine and left 

shoulder, the reports are of limited probative value as the physicians failed to state any opinion 

on the cause of appellant’s injury.14 The physical therapy notes dated October 15 through 

December 28, 2012 are also insufficient to establish appellant’s claim as they were not signed by 

 9 Ceferino L. Gonzales, 32 ECAB 1591 (1981). 

10 See Lee R. Haywood, 48 ECAB 145 (1996). 

11 See L.M., Docket No. 14-973 (issued August 25, 2014); R.G., Docket No. 14-113 (issued April 25, 2014); 

K.M., Docket No. 13-1459 (issued December 5, 2013); A.J., Docket No. 12-548 (issued November 16, 2012). 

12 S.E., Docket No. 08-2214 (issued May 6, 2009); C.B., Docket No. 09-2027 (issued May 12, 2010).

13 See Calvin E. King, Jr., 51 ECAB 394 (2000); see also Frederick E. Howard, Jr., 41 ECAB 843 (1990). 

14 Supra note 12. 
9

a physician. Registered nurses, physical therapists, and physician assistants are not considered 

physicians as defined under FECA. Thus, their opinions are of no probative value.15

The Board has held that the mere fact that a condition manifests itself during a period of 

employment does not raise an inference of causal relation.16 An award of compensation may not 

be based on surmise, conjecture, speculation, or on the employee’s own belief of causal 

relation.17 Appellant’s honest belief that the September 12, 2012 employment incident caused 

her medical injury is not in question, but that belief, however sincerely held, does not constitute 

the medical evidence necessary to establish causal relationship. To establish a firm medical 

diagnosis and causal relationship, appellant must submit a physician’s report in which the 

physician reviews those factors of employment alleged to have caused her condition and, taking 

these factors into consideration, as well as findings upon examination and appellant’s medical 

history, explain how these employment factors caused or aggravated any diagnosed condition, 

and present medical rationale in support of his opinion.18 

In the instant case, the record lacks rationalized medical evidence establishing a causal 

relationship between the September 12, 2012 employment incident and the thoracic disc 

herniation at T7-8 and left shoulder labral tear. Thus, appellant has failed to meet her burden of 

proof. 

Appellant may submit additional evidence, together with a written request for 

reconsideration, to OWCP within one year of the Board’s merit decision, pursuant to 5 U.S.C. 

§ 8128(a) and 20 C.F.R. §§ 10.606 and 10.607.19

CONCLUSION 

The Board finds that appellant did not meet her burden of proof to establish that she 

sustained an injury causally related to the September 12, 2012 employment incident. 

 15 5 U.S.C. § 8101(2) of FECA provides as follows: “(2) ‘physician’ includes surgeons, podiatrists, dentists, 

clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as 

defined by State law.” See also Roy L. Humphrey, 57 ECAB 238 (2005). 

16 Daniel O. Vasquez, 57 ECAB 559 (2006). 

17 D.D., 57 ECAB 734 (2006). 

18 Supra note 10. 

19 The record contains a Form CA-16 signed by the employing establishment official on September 12, 2012. 

When the employing establishment properly executes a Form CA-16 which authorizes medical treatment as a result 

of an employee’s claim for an employment-related injury, the CA-16 Form creates a contractual obligation, which 

does not involve the employee directly, to pay for the cost of the examination or treatment regardless of the action 

taken on the claim. The period for which treatment is authorized by a Form CA-16 is limited to 60 days from the 

date of issuance, unless terminated earlier by OWCP. See 20 C.F.R. § 10.300(c); Tracy P. Spillane, 54 ECAB 

608 (2003). The record is silent as to whether OWCP paid for the cost of appellant’s examination or treatment for 

the period noted on the form. 
10

ORDER 

IT IS HEREBY ORDERED THAT the Office of Workers’ Compensation Programs’ 

decision dated September 9, 2015 is affirmed. 

Issued: June 23, 2016 

Washington, DC 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board