United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

E.G., Appellant 

and 

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS ADMINISTRATION MEDICAL 

CENTER, Houston, TX, Employer 

__________________________________________ 

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Docket No. 16-0242 

Issued: October 14, 2016 

Appearances: Case Submitted on the Record

Alan J. Shapiro, Esq., for the appellant1

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 November 24, 2015 appellant, through counsel, filed a timely appeal from an 

October 2, 2015 merit decision of the Office of Workers’ Compensation Programs (OWCP). 

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

 In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for 

legal or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. 

§ 501.9(e). No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An 

attorney or representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject 

to fine or imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a 

representative, prior to approval by the Board, may be reported to appropriate authorities for investigation. 

2

 5 U.S.C. § 8101 et seq. 
2

ISSUE 

The issue is whether appellant has met his burden of proof to establish right shoulder and 

cervical spine injuries causally related to an accepted March 1, 2014 employment incident. 

FACTUAL HISTORY 

On March 5, 2014 appellant, then a 58-year-old electrician, filed a traumatic injury claim 

(Form CA-1) alleging that on March 1, 2014 he sustained injuries to the right shoulder and the 

top of his head when the roller mechanism of an overhead door fell from its track and struck him. 

He provided photographs of the two roller pins and a metal hinge, and a March 7, 2014 repair 

invoice noting that two 3-inch rollers and a hinge had to be replaced. The employing 

establishment issued an authorization for examination and/or treatment (Form CA-16) on 

March 5, 2014 describing appellant’s injury as “top of head, right shoulder pain.” Appellant was 

off work from March 6 to 10 and April 15 and 16, 2014. He provided a coworker’s statement 

corroborating that on March 1, 2014 appellant was “holding his head down rubbing his right 

shoulder, bleeding from his head and he had blood in his right hand.” Appellant stated that parts 

of the overhead door had fallen on him. The coworker brought him towels to staunch the 

bleeding and then took him to the employing establishment’s emergency room. 

Dr. Molham Aldeiri, an employing establishment physician who treated appellant on an 

emergency basis immediately following the March 1, 2014 incident, noted that a computerized 

tomography (CT) scan of appellant’s head was negative for brain injury. He diagnosed a small 

hematoma of the scalp and released appellant to work. 

Dr. Lubor Jarolimek, an attending orthopedic surgeon, noted on March 5, 2014 that 

appellant had sustained an “abrasion and laceration to his head and injured his right shoulder” on 

March 1, 2014 when the door mechanism fell on him. On examination he found “muscle spasm 

right trapezius and posterior shoulder,” muscle spasm in the right-sided cervical paraspinals, and 

a healing scalp laceration. Dr. Jarolimek diagnosed a parietal laceration/hematoma, cervical 

spine sprain, and right shoulder sprain. He attributed these injuries to the March 1, 2014 

incident. Dr. Jarolimek released appellant to restricted duty. He prescribed a transcutaneous 

electrical nerve stimulator unit. Appellant presented on March 6, 2014 with continued head, 

neck, and right shoulder pain, nausea, and vomiting. Dr. Jarolimek observed continued right 

shoulder and cervical spasm, right shoulder swelling, and a healing parietal laceration. He 

prescribed physical therapy.3

In reports from April 2 to 15, 2014, Dr. Jarolimek related that appellant continued to 

complain of severe right shoulder pain, migraines, and blurry vision. Physical therapy had not 

relieved his symptoms. Appellant’s right shoulder motion was still significantly restricted on the 

April 15, 2014 examination. Dr. Jarolimek prescribed additional physical therapy. 

In an April 30, 2014 letter, Dr. Jarolimek opined that appellant was injured at work on 

March 1, 2014 “when an overhead door fell on his head, hitting him on the shoulder. [Appellant] 

had abrasion and laceration to his head, injuring his right shoulder as well.” 

 3

 Appellant participated in physical therapy from March to July 2014. 
3

On May 1, 2014 the employing establishment’s compensation manager controverted the 

claim, contending that appellant provided divergent accounts of the March 1, 2014 injury, 

confusing his physicians and rendering their reports of no probative value. 

Dr. Steven B. Inbody, an attending Board-certified neurologist, evaluated appellant on 

May 12, 2014. He noted appellant’s history of bilateral median nerve releases and a left rotator 

cuff repair. Dr. Inbody related that on March 1, 2014 appellant was struck by door parts that fell 

from 20 feet above him, striking his head and knocking him “to the ground with altered mental 

status.” He diagnosed postconcussion syndrome, with a “probable cervical spine injury causing 

cervicocranial headaches, dizziness, and blurred vision.”4

Appellant stopped work on May 13, 2014 and did not return. 

On May 15, 2014 OWCP accepted that appellant sustained a scalp contusion, right 

shoulder and upper arm sprain, and neck sprain causally related to the March 1, 2014 incident. 

In a May 27, 2014 investigative memorandum, the employing establishment 

acknowledged that on March 1, 2014 appellant tried to close a misaligned overhead door. A 

metal roller, which weighed nine ounces, fell from a height of 19 feet onto his head. 

By notice dated June 17, 2014, OWCP advised appellant that it proposed to rescind 

acceptance of his claim, as the employing establishment contended that only one, small, nineounce object struck him in the head, without contacting or injuring any other part of his body. It 

afforded appellant 30 days to submit additional evidence in support of his claim. 

Appellant responded by June 22, 2014 letter, explaining that two metal roller pins and a 

door hinge fell on him, with one of the three items striking his head, and another his right 

shoulder. As these metal items fell from a height of 20 feet, the impact was sufficient to knock 

him to the ground. A coworker took appellant to the emergency room within minutes of the 

incident. Appellant contended that his supervisor sought to embarrass him for filing a 

compensation claim. 

Dr. Clark D. McKeever, an attending Board-certified orthopedic surgeon, submitted a 

June 24, 2014 report relating that on March 1, 2014 appellant was closing a large overhead door 

when it malfunctioned and “parts of metal fell onto his head and right shoulder and knocked him 

to the ground.” Appellant was taken immediately to a hospital emergency room, where he was 

diagnosed with a scalp hematoma and contusion/strain injuries to the neck and right shoulder. 

On examination, Dr. McKeever found restricted motion of the cervical spine and right shoulder. 

He diagnosed cervical radiculopathy, cervical disc protrusion or herniation at C5-6 and C7-T1, 

and a right rotator cuff tear. Dr. McKeever recommended arthroscopic rotator cuff repair. 

 4

 A May 29, 2014 magnetic resonance imaging (MRI) scan of appellant’s brain was normal. A May 30, 2014 

MRI scan of appellants’ cervical spine showed a central to right-sided disc protrusion at C7-T1 and a C5-6 central 

disc protrusion with mild bilateral foraminal stenosis. A May 31, 2014 of the right shoulder showed partial surface 

tears of the supraspinatus and infraspinatus tendons, and a spinoglenoid notch cyst. 
4

Dr. Jarolimek provided a July 1, 2014 report, relating that on March 1, 2014 when 

appellant activated the electronic switch to close a large overhead door, the track mechanism 

malfunctioned “and parts of the door shot out, and impacted him on the head and right shoulder, 

causing a laceration to his scalp and pain in his right shoulder. The malfunctioned parts that shot 

out towards [appellant] were rollers and brackets.” Appellant received immediate treatment in 

an emergency room, where he was diagnosed with a scalp laceration and hematoma. 

By decision dated July 23, 2014, OWCP rescinded acceptance of the claim, finding that 

there were significant factual inconsistencies regarding the March 1, 2014 incident. It found that 

“[a]ll of the medical reports [were] inconsistent in their mechanism of injury.” 

Appellant disagreed and requested a telephonic hearing, held on March 10, 2015. At the 

hearing, he explained that on March 1, 2014 while repairing an overhead door, the electric motor 

malfunctioned, ejecting two roller pins, and a bracket from a height of 20 feet. These 

components struck appellant in the head and right shoulder. In a written statement, appellant 

explained that he was assigned to repair the electric driver motor of an overhead door. When he 

activated a switch as part of the repair process, the door malfunctioned, causing the rods, pins, 

and brackets to turn into projectiles because the door motor was still running. The force of these 

objects, falling from a height of 20 feet, caused a laceration on his head and an impact injury to 

his right shoulder. A coworker found appellant immediately after the incident and took him to 

the emergency room. Appellant alleged that the supervisors harassed him for filing the claim 

and sought to discredit him. He submitted photographs of the two roller pins and a bracket that 

he alleged had fallen from the door. 

An employing establishment supervisor contended in an April 9, 2015 letter that it could 

not be determined with certainty which components struck appellant, although he had submitted 

photographs of them. The supervisor acknowledged that he ordered two replacement rods and a 

bracket to repair the door following appellant’s injury, corresponding to the broken door parts in 

the photograph appellant provided. 

In a May 14, 2015 letter, an injury compensation supervisor alleged that it could not be 

determined how appellant was injured. He contended that one falling component could not have 

struck appellant multiple times. 

Appellant also provided additional medical evidence.5

 In a June 24, 2014 addendum, 

Dr. McKeever opined that, based on the cervical MRI scan report, the March 1, 2014 incident 

also resulted in the diagnosed cervical disc herniations. Dr. Inbody submitted a July 30, 2014 

letter, asserting that appellant was totally disabled and required surgery to repair a torn right 

rotator cuff and multilevel cervical disc herniations. 

In an August 7, 2014 report, Dr. Jarolimek reiterated that metal parts which fell from a 

malfunctioning overhead door struck appellant’s head. He noted reviewing photographs of the 

door parts provided by appellant. Dr. Jarolimek opined that appellant’s “work[-]related injury to 

his head, neck, and right shoulder [was] a direct result of” the malfunctioning automatic door, 

which ejected metal parts that struck appellant’s head, right shoulder, and cervical spine. He 

 5

 Appellant also submitted physical therapy notes dated from July through October 2014. 
5

added that because the metal parts struck appellant’s head, it was “reasonable to include 

[appellant’s] neck[-]related symptoms as part of his work-related injury.” Dr. Jarolimek held 

appellant off work. 

By decision dated and finalized June 5, 2015, an OWCP hearing representative affirmed 

as modified the July 23, 2014 decision, finding that appellant sustained a traumatic head injury 

on March 1, 2014, but did not sustain cervical spine and right shoulder injuries. The hearing 

representative accepted as factual that appellant sustained this injury when struck by a metal 

object falling from an overhead door. 

Appellant disagreed and, in an August 5. 2015 letter, received on August 28, 2015, 

requested reconsideration. He reiterated that on March 1, 2014 metal components of a 

malfunctioning overhead door fell from a height of 20 feet, striking his head and right shoulder. 

Appellant submitted copies of evidence previously of record. 

In a June 10, 2015 statement, the coworker who found appellant on March 1, 2014 and 

took him to the emergency room affirmed that there were rollers and brackets on the floor at the 

time of the incident. Appellant stated that these parts struck his head and right shoulder. 

In June 26, 2015 reports, Dr. Inbody opined that appellant’s right shoulder injury was 

well documented by Dr. Jarolimek shortly after March 1, 2014. As physical therapy was not 

effective, appellant underwent right rotator cuff surgery. Dr. Inbody asserted that “the 

mechanism of injury involved one or more rollers falling from a door which lacerated 

[appellant’s] right occipital parietal region with a second roller if not the same impacting the 

right supraspinatus region on the right shoulder. This caused a lump or hematoma,” both of 

which were addressed by Dr. Jarolimek. Dr. Inbody explained that the downward axial force of 

the falling door components resulted in cervical disc herniations. He noted that appellant had 

recently undergone right rotator cuff surgery. 

Dr. Jarolimek provided a July 15, 2015 report affirming that when he examined appellant 

on March 5, 2014 four days after the March 1, 2014 injury, appellant had “injuries to his right 

shoulder.” He diagnosed a “parietal laceration/hematoma, cervical spine sprain and right 

shoulder sprain/muscle spasm.” Dr. Jarolimek reiterated that these injuries were caused by the 

door parts striking appellant on March 1, 2014. 

On July 30, 2015 OWCP accepted that on March 1, 2014 appellant sustained an open 

scalp wound without complications, and a “nontraumatic hematoma soft tissue.” 

In an October 2, 2015 decision, OWCP denied modification of the June 5, 2015 decision, 

finding that the medical evidence of record was insufficient to establish a causal relationship 

between the accepted March 1, 2014 incident and the claimed right shoulder and cervical spine 

conditions. 

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 timely filed within the applicable time 
6

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.6 

Where an employee claims that a condition not accepted or approved by OWCP was due 

to an employment injury, he or she bears the burden of proof to establish that the condition is 

causally related to the employment injury.7

 The medical evidence required to establish a causal 

relationship between a claimed condition and employment factors is rationalized medical opinion 

evidence. 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 claimed condition and 

the specific employment factors identified by the claimant.8

ANALYSIS 

OWCP accepted that appellant sustained an open scalp wound without complications, 

and a nontraumatic hematoma on March 1, 2014, when he was struck by metal parts from a 

malfunctioning overhead door. A May 27, 2014 employing establishment investigative 

memorandum corroborated that on March 1, 2014 a nine ounce metal roller fell onto appellant’s 

head from a height of 19 feet. A coworker provided detailed witness statements, corroborating 

appellant’s account of the March 1, 2014 incident. 

Appellant contended that the established March 1, 2014 incident also caused cervical 

spine and right shoulder injuries. In support of his claim, he submitted reports from 

Dr. Jarolimek, an attending orthopedic surgeon. Dr. Jarolimek opined in reports from March 5 to 

April 30, 2014 that the March 1, 2014 incident caused right shoulder and cervical spine spasms. 

On July 1, 2014 he explained that “metal rollers and brackets” impacted appellant’s head and 

right shoulder.” Dr. Jarolimek reiterated on August 7, 2014 that appellant’s cervical spine and 

right shoulder injuries were directly caused by the March 1, 2014 incident, in which metal parts 

from a malfunctioning overhead door were ejected from its drive mechanism, fell 20 feet, and 

struck him. He opined that the metal parts striking appellant’s head were a competent cause of 

his cervical disc herniations. However, Dr. Jarolimek did not explain the medical reasoning 

supporting his conclusion that the impact of a nine ounce metal roller falling from a height of 19 

feet was competent to cause a cervical spine or right shoulder injury. He did not describe the 

physical forces or stresses that could have caused the diagnosed conditions. In the absence of 

such rationale, Dr. Jarolimek’s opinion is insufficient to meet appellant’s burden of proof.9

 

Dr. Inbody, an attending Board-certified neurologist, noted on May 12, 2013 that on 

March 1, 2014 appellant was struck by metal parts which fell from a door mechanism 20 feet 

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

7 Jaja K. Asaramo, 55 ECAB 200 (2004). 

8 See E.J., Docket No. 09-1481 (issued February 19, 2010). 

9 See Jimmie H. Duckett, 52 ECAB 332 (2001); Frank D. Haislah, 52 ECAB 457 (2001) (medical reports not 

containing rationale on causal relationship are entitled to little probative value). 
7

above him. He opined that this incident caused postconcussion syndrome with dizziness and 

blurred vision, and a possible cervical spine injury. In June 26, 2015 reports, Dr. Inbody opined 

that “rollers falling from a door” caused a head laceration, and impacted the right supraspinatus 

region, causing a hematoma.” However, he did not explain precisely how metal rollers falling on 

appellant’s head would cause postconcussion syndrome. The lack of rationale reduces the 

probative quality of his report.10 Additionally, Dr. Inbody’s opinion, that the falling rollers 

caused a “possible” cervical spine injury, is of little probative value because of its speculative 

nature.11 

Dr. McKeever, an attending Board-certified orthopedic surgeon, noted on June 24, 2014 

that appellant was closing an overhead door on March 1, 2014 when “parts of metal fell onto his 

head and right shoulder and knocked him to the ground.” He diagnosed a scalp hematoma, 

cervical strain, and right shoulder contusion caused by the incident. Dr. McKeever also opined 

that the March 1, 2014 incident was sufficiently forceful to have caused the diagnosed cervical 

disc herniations. However, he did not explain the pathophysiologic mechanics whereby the 

forces and stresses of the metal door rollers striking appellant would cause the diagnosed 

shoulder contusion, cervical strain, and cervical disc herniations. The lack of medical reasoning 

supporting Dr. McKeever’s conclusions reduces the persuasiveness of his opinion.12

The Board finds that the opinions of Dr. Inbody, Dr. Jarolimek, and Dr. McKeever are 

not sufficiently rationalized to meet appellant’s burden of proof in establishing his claim. 

Therefore, OWCP’s October 2, 2015 decision is proper under the law and facts of this case. 

On appeal counsel asserts that OWCP’s October 2, 2015 decision is “contrary to law and 

fact.” As set forth above, OWCP properly found that the medical evidence is insufficiently 

rationalized to meet appellant’s burden of proof. 

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 met his burden of proof to establish right shoulder 

and cervical spine injuries causally related to an accepted March 1, 2014 scalp laceration. 

 10 Id. 

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

12 Supra note 9. 
8

ORDER 

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

Compensation Programs dated October 2, 2015 is affirmed.

Issued: October 14, 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