United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

Z.B., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Atlanta, GA, Employer

__________________________________________

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Docket No. 17-1027

Issued: November 17, 2017

Appearances: Case Submitted on the Record1

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

PATRICIA H. FITZGERALD, Deputy Chief Judge

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On April 10, 2017 appellant filed a timely appeal from a December 20, 2016 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 in this case.

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1 Appellant filed a timely request for oral argument. By order dated September 21, 2017 the Board, after 

exercising its discretion, denied her request as her arguments could be adequately addressed in a decision based on a 

review of the case record. Order Denying Request for Oral Argument, Docket No. 17-1027 (issued 

September 21, 2017).

2

5 U.S.C. § 8101 et seq.

3 With her request for an appeal, appellant submitted additional evidence. The Board’s jurisdiction is limited to 

reviewing the evidence that was before OWCP at the time of its final decision. Therefore, the Board may not 

consider this additional evidence for the first time on appeal; 20 C.F.R. § 501.2(c)(1). 
2

ISSUE

The issue is whether appellant met her burden of proof to establish a right shoulder and 

cervical injury causally related to an October 15, 2016 employment incident.

FACTUAL HISTORY

On October 26, 2016 appellant, then a 37-year-old mail carrier, filed a traumatic injury 

claim (Form CA-1), alleging that on October 15, 2016, while removing mail trays from a rack 

and loading them into a tub, she felt a sharp pain in the right side of her neck and shoulder. She 

stopped work on October 31, 2016 and returned to work on November 4, 2016. 

On October 26, 2016 appellant was treated by Dr. Shaun Brownlee, Board-certified in 

occupational medicine, who diagnosed strain of muscle, fascia, tendon at the neck, shoulder, and 

upper right arm. Dr. Brownlee noted that she could return to work on October 26, 2016 with

restrictions. He anticipated that the date of maximum medical improvement would be

November 9, 2016. In a patient referral prescription note, Dr. Brownlee diagnosed strain of 

muscle, fascia, tendon at the neck, shoulder, and upper right arm and referred appellant for 

physical therapy.

Appellant was treated by Dr. Joshua M. McNatt, a Board-certified family practitioner, on 

October 28, 2016, who diagnosed strain of muscle, fascia, tendon at the neck, shoulder, and 

upper right arm. Dr. McNatt returned her to work restricted duty, eight hours a day, on 

October 28, 2016. He noted that the anticipated date of maximum medical improvement was 

November 11, 2016.

In a verification of treatment note dated October 31, 2016, Dr. Mary R. Varghese, a 

Board-certified internist, excused appellant from work from October 31 to November 4, 2016 

and returned her to work without restrictions on November 7, 2016. The record also contains 

physical therapy records. 

By letter dated November 14, 2016, OWCP advised appellant of the type of evidence 

needed to establish her claim, particularly requesting that she submit a physician’s reasoned 

opinion addressing the relationship of her claimed condition and specific employment factors. It 

noted that medical evidence must be submitted by a qualified physician. 

Appellant was treated by Dr. Brownlee on November 4, 2016 who diagnosed strain of 

muscle, fascia, tendon at the neck, shoulder, and upper right arm. Dr. Brownlee noted that she

could work with restrictions. He anticipated that maximum medical improvement would occur 

on November 18, 2016. Dr. Brownlee treated appellant again on November 9, 2016 for right 

shoulder pain. Appellant reported right anterior shoulder pain, but indicated that her symptoms 

were improving. She attended physical therapy and demonstrated functional improvement. 

Appellant indicated that she was not working because light duty was not available. 

Dr. Brownlee noted findings on examination of joint pain, muscle pain, no joint stiffness, no

muscle weakness, the right shoulder appeared normal, full range of motion, and intact muscle 

strength bilaterally. He diagnosed right shoulder strain and cervical strain. Dr. Brownlee 
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recommended that appellant continue physical therapy. He returned her to full-time modified 

duty. 

Appellant submitted a report from Dr. McNatt dated November 16, 2016 who treated her

for right shoulder pain. She reported pain in the right lateral shoulder which was improving. 

Dr. McNatt noted findings on examination of normal gait, no tenderness or swelling of the 

extremities, normal range of motion, normal strength and tone, the right shoulder appeared

normal, palpation was normal, full range of motion, extension and abduction with pain, and 

normal motor strength bilaterally. He diagnosed right shoulder strain and released appellant 

from his care. Dr. McNatt noted that maximum medical improvement was reached and she

could return to work regular duty. OWCP also received additional physical therapy records. 

In a December 20, 2016 decision, OWCP accepted that the October 15, 2016 

employment incident occurred as alleged. However, it denied the claim finding that fact of 

injury had not been established. OWCP found that appellant failed to submit medical evidence 

sufficient to establish a diagnosed medical condition causally related to the accepted work 

incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA4has 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 filed within the applicable time 

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

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

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

regardless of whether the claim is predicated upon a traumatic injury or an occupational disease.5

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

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

There are two components involved in establishing fact of injury. First, the employee must 

submit sufficient evidence to establish that she actually experienced the employment incident at 

the time, place, and in the manner alleged. Second, the employee must submit 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

 

4

Supra note 2. 

5 Gary J. Watling, 52 ECAB 357 (2001).

6

T.H., 59 ECAB 388 (2008).

7

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

It is undisputed that on October 15, 2016 appellant was performing her mail carrier 

duties, which included removing mail trays from a rack and loading them into a tub. However, 

the Board finds that she has failed to submit sufficient medical evidence to establish that this 

work incident caused or aggravated her right shoulder and cervical strain. In a letter dated 

November 14, 2016, OWCP requested that appellant submit a comprehensive report from her 

treating physician which included a reasoned explanation as to how the accepted work incident 

had caused her claimed injury. 

The Board finds that appellant did not meet her burden of proof. 

Appellant was treated by Dr. Brownlee on November 9, 2016 for right anterior shoulder 

pain. Dr. Brownlee noted findings on examination of joint pain, muscle pain, no muscle 

weakness, the right shoulder appeared normal, full range of motion, and intact muscle strength 

bilaterally. He diagnosed right shoulder strain and cervical strain. Dr. Brownlee recommended 

that appellant continue physical therapy and returned to full-time modified duty. Similarly, in 

reports dated October 26 and November 4 2016, he diagnosed strain of muscle, fascia, tendon at 

the neck, shoulder, and upper right arm and noted that she could return to work restricted duty on 

October 26, 2016. Likewise, in a patient referral form, Dr. Brownlee noted diagnoses and

referred appellant for physical therapy. His notes are insufficient to establish the claim as he did 

not provide a history of injury8or specifically address whether her employment activities had 

caused or aggravated a diagnosed medical condition.9 

Appellant submitted an October 28, 2016 report from Dr. McNatt who diagnosed strain 

of muscle, fascia, tendon at the neck, shoulder, and upper right arm. Dr. McNatt returned her to 

restricted duty on October 28, 2016. In a November 16, 2016 report, he treated appellant for 

right shoulder pain. Dr. McNatt noted an essentially normal examination and diagnosed right 

shoulder strain. He released appellant from his care noting maximum medical improvement was 

reached. Dr. McNatt noted that she could return to work regular duty. Similarly, these notes are 

insufficient to establish appellant’s claim as he did not provide a history of injury10 or 

specifically address whether her employment activities had caused or aggravated a diagnosed 

medical condition.11

The remainder of the medical evidence, including an October 31, 2016 verification of 

treatment note from Dr. Varghese, is of limited probative value as it fails to provide a physician’s 

 

8 Frank Luis Rembisz, 52 ECAB 147 (2000) (medical opinions based on an incomplete history or which are 

speculative or equivocal in character have little probative value). 

9 A.D., 58 ECAB 149 (2006); Docket No. 06-1183 (issued November 14, 2006) (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 Frank Luis Rembisz, supra note 8. 

11 A.D., supra note 9. 
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opinion on the causal relationship between appellant’s work incident and her diagnosed right 

shoulder and cervical strain.

12 Thus, this evidence is insufficient to meet her burden of proof. 

The record also contains physical therapy treatment records. The Board has held that 

notes signed by a physical therapist are not considered medical evidence as they are not 

physicians under FECA.13 Thus, these treatment records are of no probative medical value in 

establishing appellant’s claim. 

An award of compensation may not be based on surmise, conjecture, or speculation. 

Neither the fact that appellant’s condition became apparent during a period of employment nor 

the belief that her condition was caused, precipitated, or aggravated by her employment is 

sufficient to establish causal relationship. Causal relationships must be established by 

rationalized medical opinion evidence.14 Appellant failed to submit such evidence and therefore 

she has not met her burden of proof.

On appeal appellant contends that she submitted sufficient medical evidence in support of 

her claim. She notes that OWCP’s decision incorrectly indicated a date of injury of October 15, 

2015 when the injury actually occurred on October 15, 2016. The Board finds this date disparity 

as harmless error as it does not go to the substance of the claim. Appellant advised that her 

injury was immediately reported and medical treatment was obtained the same day. As found

above, however, the medical evidence of record is insufficient to establish a diagnosed medical 

condition causally related to the accepted work incident. Appellant has not submitted a 

physician’s report which addresses how the work incident on October 15, 2016 caused or 

aggravated a right shoulder and cervical strain. 

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 did not meet her burden of proof to establish a right 

shoulder and cervical injury causally related to the accepted October 15, 2016 employment 

incident.

 

12 See id.

13 See David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006) (lay individuals such as physician assistants, 

nurses, and physical therapists are not competent to render a medical opinion under FECA); 5 U.S.C. § 8101(2) (this 

subsection defines a “physician” as surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, 

and osteopathic practitioners within the scope of their practice as defined by State law). 

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

IT IS HEREBY ORDERED THAT the December 20, 2016 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: November 17, 2017

Washington, DC

Patricia H. Fitzgerald, Deputy 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