United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

T.T., Appellant

and

DEPARTMENT OF AGRICULTURE, FOOD 

SAFETY & INSPECTION SERVICE, 

Kinston, NC, Employer

__________________________________________

)

)

)

)

)

)

)

)

)

Docket No. 17-1084

Issued: April 2, 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 April 24, 2017 appellant filed a timely appeal from a December 2, 2016 merit decision 

of the Office of Workers’ Compensation Programs (OWCP).1 Pursuant to the Federal Employees’

Compensation Act2(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over 

the merits of this case.

 

1 Appellant timely requested oral argument before the Board. By order dated December 19, 2017, the Board 

exercised its discretion pursuant, to 20 C.F.R. § 501.5(a), and denied the request, finding that the issues could properly 

be adjudicated based on the evidence of record. Order Denying Request for Oral Argument, Docket No. 17-1084 

(issued December 19, 2017).

2 5 U.S.C. § 8101 et seq. 
2

ISSUE

The issue is whether appellant has established that he sustained renal failure and posttraumatic stress disorder (PTSD) consequential to his accepted bilateral upper extremity 

conditions.

FACTUAL HISTORY

On May 15, 2012 appellant, then a 30-year-old food inspector, filed an occupational 

disease claim (Form CA-2) alleging that performance of repetitive upper extremity movements

while inspecting poultry, resulted in bilateral carpal tunnel syndrome, bilateral cubital tunnel 

syndrome, and a right trigger thumb. He stopped work on May 14, 2012. OWCP initially accepted 

appellant’s claim for bilateral carpal tunnel syndrome. Appellant received wage-loss 

compensation on the supplemental rolls commencing May 15, 2012 and on the periodic rolls 

commencing July 1, 2012.

On June 12, 2012 Dr. Semaan El-Khoury, an attending internist, prescribed nonsteroidal 

anti-inflammatories (NSAIDs) to treat the accepted carpal tunnel syndrome.

Dr. Lawrence N. Larabee, Jr., an attending Board-certified orthopedic surgeon, diagnosed 

bilateral carpal tunnel syndrome on June 29, 2012.3 He returned appellant to light duty. On

September 11, 2012 report, Dr. Larabee diagnosed tendinitis of the right thumb and administered 

a steroid injection. He recommended on October 2, 2012 that appellant take nonprescription 

NSAIDs and wear prescribed splints.

On October 15, 2012 appellant returned to work for two hours a day. OWCP paid appellant 

wage-loss compensation benefits. Dr. Larabee held appellant off work from December 5, 2012 

onward pending a right carpal tunnel release. OWCP paid appellant compensation for temporary 

total disability commencing December 16, 2012. On December 17, 2012 it expanded acceptance 

of the claim to include bilateral cubital tunnel syndrome, and right trigger finger.

On January 31, 2013 Dr. Larabee performed an authorized right carpal tunnel release. On 

April 18, 2013 he performed an authorized left carpal tunnel release and authorized left ulnar nerve 

transposition. Appellant remained off work. Dr. Larabee released appellant to full, unrestricted 

duty as of July 24, 2013.

By decision dated August 19, 2013, OWCP issued appellant a schedule award for three 

percent permanent impairment of each upper extremity. Following additional development, by 

decision dated February 2, 2015, it found that the medical evidence of record established that 

appellant had 14 percent permanent impairment of the right upper extremity and 17 percent 

permanent impairment of the left upper extremity.

 

3 An August 8, 2012 electromyography (EMG) study demonstrated bilateral carpal tunnel syndrome. A 

November 29, 2012 EMG and nerve conduction velocity study showed bilateral carpal tunnel syndrome, right greater 

than left.
3

In a November 27, 2013 report, Dr. Larabee found that appellant’s right hand clawing had 

worsened. He diagnosed advancing right cubital tunnel syndrome and ulnar nerve 

mononeuropathy. Dr. Larabee held appellant from work. OWCP paid appellant compensation for 

total disability on the periodic rolls.

On May 22, 2014 Dr. Larabee performed an authorized right carpal tunnel release, right 

ulnar nerve artery repair, and right ulnar nerve release at the wrist.

In a July 29, 2014 report, Dr. Larabee diagnosed chronic ulnar clawing of the right hand. 

He noted that appellant was on kidney dialysis and was “very sick and in the hospital.” He 

prescribed Percocet for hand pain.

In August 19 and 20, 2014 reports, Dr. Larabee found appellant permanently and totally 

disabled from all work due to severe clawing of the right hand. He submitted periodic progress 

reports.

On April 19, 2015 appellant filed an occupational disease claim (Form CA-2) alleging that,

on or before June 27, 2014, he sustained renal failure and PTSD consequential to the accepted 

bilateral upper extremity conditions.

In an April 30, 2015 development letter, OWCP notified appellant of the additional 

evidence needed to establish his claim, including a detailed narrative report from his attending 

physician explaining how and why the accepted bilateral upper extremity conditions or their 

treatment would cause renal failure and PTSD. It afforded appellant 30 days to submit such 

evidence.4

In response, appellant submitted an October 4, 2015 letter in which he asserted that the 

medications he took for the accepted bilateral carpal tunnel syndrome worsened his kidney 

condition. He provided medical literature from internet websites on analgesic nephropathy. There 

was no evidence submitted relative to the PTSD claim.

On July 16, 2015 Dr. Larabee performed an authorized right anterior ulnar nerve 

transposition at the elbow. In a September 30, 2015 report, he opined that appellant had attained 

maximum medical improvement. Dr. Larabee found that appellant remained permanently and 

totally disabled for work.

By decision dated November 3, 2015, OWCP denied appellant’s claim for consequential 

PTSD and renal failure as the medical evidence of record did not contain sufficient medical 

rationale to establish causal relationship of the conditions of renal failure and PTSD.

 

 

4 By decision dated April 30, 2015, OWCP denied appellant’s claims for travel reimbursement on intermittent dates 

from November 29, 2012 to March 17, 2015. By decision dated May 6, 2015, it denied appellant’s claim for attendant 

services as the evidence of record did not establish that such services were necessary under 5 U.S.C. § 8111(a). On 

May 12, 2015 appellant requested reconsideration of OWCP’s May 6, 2015 decision. By decision dated June 8, 2015, 

OWCP denied modification as additional evidence did not establish that attendant services were necessary under 5 

U.S.C. § 8111(a).
4

On October 24, 2016 appellant requested reconsideration. He submitted additional 

evidence which he contended established his claim.

In a February 4, 2015 report, Dr. Graham V. Bynum, Jr., an attending Board-certified 

internist specializing in nephrology, noted that appellant had been diagnosed with human 

immunodeficiency virus (HIV) prior to beginning dialysis in June 2014. He had been recently 

weaned off dialysis.

In an October 5, 2015 report, Dr. Bynum diagnosed end stage renal disease (ESRD) and 

recommended a kidney transplant. He noted in a December 21, 2015 letter that appellant should 

avoid NSAID drugs as they could “cause his chronic kidney disease to worsen more quickly.”

5

In an October 23, 2016 report, Dr. Bynum explained that the etiology of appellant’s “endstage renal disease is biopsy proven HIV nephropathy.” The biopsy also demonstrated interstitial 

nephritis superimposed on glomerular changes characteristic of chronic renal disease. Dr. Bynum 

opined that appellant’s longstanding use of NSAIDs “more likely than not accelerated the 

progression of his underlying chronic kidney disease and, in addition to that, probably created 

NSAID-related interstitial nephritis which, again, would accelerate his underlying chronic kidney 

disease.”

In an October 31, 2016 letter, OWCP requested that Dr. Bynum submit a rationalized 

medical report differentiating between chronic kidney disease resulting from NSAID exposure and 

HIV nephropathy. Dr. Bynum responded by November 18, 2016 letter. He noted that appellant’s 

“renal biopsy findings were consistent with HIV nephropathy” with a significant interstitial 

inflammatory infiltrate. Dr. Bynum noted that appellant had taken prescription and over-thecounter NSAIDs to treat carpal tunnel syndrome. He opined that it was more likely than not that 

appellant’s “heavy use of NSAIDs would accelerate progression to ESRD.” Dr. Bynum explained 

that NSAIDs were one cause of interstitial nephritis, but that other causes could not be ruled out 

in appellant’s case. He noted that he did not treat appellant during his use of NSAID medication, 

and had not reviewed appellant’s treatment records. Dr. Bynum emphasized, however, that “based 

on medical literature relating to NSAID use in the setting of CKD [chronic kidney disease] and 

from [his] clinical experience it was more likely than not” that appellant’s NSAID use accelerated 

his chronic kidney disease.

By decision dated December 2, 2016, OWCP denied modification as the medical evidence 

of record was insufficient to establish causal relationship. It found that Dr. Bynum’s reports were 

insufficiently rationalized to establish causal relationship between appellant’s ESRD and NSAID 

use related to the accepted upper extremity conditions. OWCP also found that Dr. Bynum’s 

opinion was diminished by his incomplete knowledge of the case, as he did not review medical 

records from the two-year period that appellant had taken NSAID medication.

 

 

5

In a September 6, 2016 report, Dr. Harrison G. Tuttle, an attending Board-certified orthopedic surgeon, noted 

appellant’s complaints of increased right hand pain and weakness. He noted that appellant was on dialysis for chronic 

renal failure. Dr. Tuttle commented that the cause of appellant’s renal failure was not clear, but could be related to 

his HIV infection.
5

LEGAL PRECEDENT

A claimant bears the burden of proof to establish a claim for a consequential injury. As 

part of this burden, he or she must present rationalized medical opinion evidence, based on a 

complete factual and medical background, showing causal relationship. The opinion must be one

of reasonable medical certainty and must be supported by medical rationale explaining the nature 

of the relationship of the diagnosed condition and the specific employment factors or employment 

injury.6

In discussing the range of compensable consequences, once the primary injury is causally 

connected with the employment, Larson notes that, when the question is whether compensability 

should be extended to a subsequent injury or aggravation related in some way to the primary injury, 

the rules that come into play are essentially based upon the concepts of direct and natural results 

and of the claimant’s own conduct as an independent intervening cause. The basic rule is that a 

subsequent injury, whether an aggravation of the original injury or a new and distinct injury, is 

compensable if it is the direct and natural result of a compensable primary injury.7

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

claimed and the employment injury, an employee must submit rationalized medical evidence based 

on a complete medical and factual background supporting causal relationship.8 Causal relationship 

is a medical issue and the medical evidence required to establish a causal relationship is 

rationalized medical evidence. A medical report is of limited probative value on a given medical 

question if it is unsupported by medical rationale.9 Medical rationale includes a physician’s 

detailed opinion on the issue of whether there is causal relationship between the claimant’s 

diagnosed condition and the implicated employment activity. The opinion of the physician must 

be based on a complete factual and medical background of the claim, 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 specific employment activity or factors 

identified by the claimant.10 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.11

 

6 See Charles W. Downey, 54 ECAB 421 (2003).

7 Larson, The Law of Workers’ Compensation § 1300; P.J., Docket No. 17-0570 (issued October 26, 2017); K.S., 

Docket No. 16-0404 (issued April 11, 2016).

 

8 M.W., 57 ECAB 710 (2006); John D. Jackson, 55 ECAB 465 (2004). 

 

9 T.F., 58 ECAB 128 (2006). 

 

10 A.D., 58 ECAB 149 (2006).

 

11 A.C., Docket No. 08-1453 (issued November 18, 2008). 
6

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish that he sustained 

renal failure and PTSD consequential to his accepted bilateral upper extremity conditions.

As appellant did not submit any medical evidence addressing PTSD, he has failed to meet 

his burden of proof with regard to this condition.12 

Appellant submitted several medical reports which address his kidney disease. Dr. Bynum, 

an attending Board-certified internist specializing in nephrology, opined in an October 23, 2016

report that appellant’s ESRD was due to “biopsy proven HIV nephropathy” superimposed on 

chronic renal disease. He explained that appellant’s longstanding NSAID use for treatment of the 

accepted bilateral carpal tunnel syndrome “more likely than not” accelerated underlying chronic 

kidney disease and “probably created NSAID-related interstitial nephritis.” The Board finds that 

the probative value of Dr. Bynum’s opinion is diminished by its equivocal nature.13 It lacks the 

definite, unambiguous quality of the evidence needed to meet appellant’s burden of proof in 

establishing causal relationship.14

In response to OWCP’s October 31, 2016 request for clarification, Dr. Bynum provided a 

November 18, 2016 report in which he noted that he had not treated appellant during the time he 

took NSAID medication and, as such, did not have access to those treatment records. The Board 

has held that medical opinions not based on a complete medical and factual history are of 

diminished probative value.15 As Dr. Bynum did not review the treatment records, serology 

reports, prescription records, laboratory tests, and other relevant material related to appellant’s 

NSAID use, his opinion is insufficient to meet appellant’s burden of proof in establishing causal 

relationship. 

OWCP notified appellant by April 30, 2015 letter of the additional evidence needed to 

establish his claim for consequential injury, including his physician’s well-reasoned opinion that 

supported a pathophysiologic connection between NSAID use and the development of kidney 

disease and PTSD. As appellant did not submit such evidence, he did not meet his burden of proof.

On appeal appellant contends that OWCP unreasonably delayed adjudicating his claims 

and required unnecessary referral examinations. The Board notes that there is no evidence of 

record that OWCP erred or abused its discretion in processing appellant’s claims.

 

12 Supra note 6. 

13 Ricky S. Storms, 52 ECAB 349 (2001).

14 Id.

 

15 See Douglas M. McQuaid, 52 ECAB 382 (2001) (medical reports must be based on a complete and accurate 

factual and medical background and medical opinions based on an incomplete or inaccurate history are of little 

probative value).
7

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 established that he sustained renal failure and PTSD 

consequential to his accepted bilateral upper extremity conditions. 

ORDER

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

Programs dated December 2, 2016 is affirmed.

Issued: April 2, 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