United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

S.Y., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Eureka, CA, Employer

__________________________________________

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Docket No. 18-1814

Issued: April 18, 2019

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

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On September 28, 2018 appellant, through counsel, filed a timely appeal from an August 2, 

2018 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 her burden of proof to establish back and right 

shoulder conditions causally related to the accepted September 28, 2017 employment incident.

FACTUAL HISTORY

On October 1, 2017 appellant, then a 38-year-old mail handler, filed a traumatic injury 

claim (Form CA-1) alleging that, on September 28, 2017, she developed a back contusion, upper 

back strain, and a right shoulder injury while in the performance of duty. She stopped work on 

September 29, 2017. On the reverse side of the claim form, the postmaster controverted the claim, 

contending that appellant told management that she had a preexisting injury and that her shoulder 

was sore the prior week. 

Subsequently, in an undated letter, appellant described the alleged September 28, 2017 

employment incident. She advised that management gave her a direct order to change out 

overloaded containers from a belt. Appellant pulled a container overloaded with parcels and 

magazines from the backside of the belt and tried to go forward with it, but it would not move. 

She indicated that the container, which weighed approximately 500 pounds, seemed to have a 

broken wheel. Appellant reported the problem to management and was instructed to move the 

container again. She could not move it forward and, as a result, felt a pinch in her shoulder. 

Appellant reported her injury to management. After a manager unsuccessfully tried to move the 

container, he directed appellant to pull the container to the back of the building to be dealt with 

later. After so doing, appellant claimed that her shoulder pain intensified. 

Appellant submitted an undated patient visit information form by Celine Pele, a certified 

physician assistant, who indicated that appellant was seen on September 29, 2017 for upper back 

strain, diagnosed back “contusion,” and provided aftercare instructions. In an undated work 

release form, Ms. Pele noted that appellant may return to work on October 13, 2017 without

restrictions. 

Appellant also submitted an October 9, 2017 patient visit information form by Dr. Diana L. 

Yandell, a physician specializing in emergency medicine. Dr. Yandell provided aftercare 

instructions for appellant’s diagnosis of neck sprain or strain. In a work release form of the same 

date, she advised that appellant may return to work on October 16, 2017 without restrictions. 

In statements received on October 12, 2017 appellant’s supervisor and postmaster, 

controverted the claim, respectively, primarily contending that appellant did not report an injury 

to either supervisor or to her coworkers. 

By development letter dated October 19, 2017, OWCP advised appellant of the factual and 

medical deficiencies of her claim. It provided a questionnaire for her completion regarding the 

circumstances of the injury. Appellant was also asked to provide a narrative medical report from 

her physician which contained a detailed description of findings and diagnoses, explaining how 

the reported incident caused or aggravated her medical condition. OWCP afforded 30 days for 

response.
3

A medical report dated October 16, 2017 by Dr. William S. Harden, a Board-certified 

family practitioner, listed the date of injury as September 28, 2017. He related a history that 

appellant’s supervisor instructed her to push a 500-pound cage. After doing so, appellant

developed pain in her right shoulder down to her right arm for which she sought medical treatment 

on the next day. Dr. Harden reported findings on physical examination and diagnosed apparent 

right shoulder strain. He placed appellant off work from the date of his examination through 

November 15, 2017 due to work-related injuries. 

In a statement received on October 27, 2017, appellant reiterated the factual history of her 

claim and again asserted that the September 28, 2017 employment incident caused her shoulder 

and back injuries.

Ms. Pele, in a report also received on October 27, 2017, diagnosed upper back strain and 

placed appellant off work until she was cleared by occupational health. 

In an October 27, 2017 statement, appellant again described the claimed September 28, 

2017 employment incident and maintained that she reported her right shoulder injury to both her 

supervisor and coworkers. She submitted statements from her coworker, which addressed the 

September 28, 2017 incident and her claimed right shoulder injury. 

OWCP subsequently received x-ray reports dated October 25, 2017 by Dr. Ashlesha 

Sharma, an osteopathic physician specializing in radiology. Dr. Sharma reported that an x-ray of 

the cervical spine revealed an impression of no fracture and no significant degenerative change. 

She reported that a right shoulder x-ray revealed an impression of acromioclavicular and 

glenohumeral joints that appeared normal and no fracture or significant degenerative change. 

An October 25, 2017 right shoulder magnetic resonance imaging (MRI) scan report by

Dr. Adam A. Attoun, a Board-certified diagnostic radiologist, provided an impression of findings 

suggesting tendinosis of the rotator cuff without evidence of full-thickness discontinuity or 

retraction and mild tenosynovitis involving the long head of the biceps tendon. Dr. Attoun found 

no conclusive evidence of subacromial impingement or glenohumeral joint effusion.

In a progress note dated September 19, 2017, Dr. Jane E. Sonneland, a Board-certified 

family practitioner, assessed left scapular strain, resolving, that was presumed from repetitive 

motion activities both at home and work.

In an emergency department report dated October 9, 2017, Dr. Yandell noted that appellant 

sustained a back injury on September 28, 2017 while pulling a very heavy object. She discussed 

her medical background and findings on physical examination. Dr. Yandell provided a primary 

impression of upper back strain. 

An additional prescription note dated November 13, 2017 by Dr. Harden set forth

appellant’s work restrictions through January 15, 2018.3 

 

3 On November 15, 2017 the employing establishment offered appellant a modified mail handler position, which 

she accepted on that date. 
4

By decision dated November 20, 2017, OWCP denied appellant’s traumatic injury claim, 

finding that the medical evidence of record was insufficient to establish that her diagnosed upper 

back and neck conditions were causally related to the accepted September 28, 2017 employment 

incident. 

On December 1, 2017 appellant, through counsel, requested a telephonic hearing before an 

OWCP hearing representative. 

Dr. Harden, in a progress report dated January 15, 2018, noted that appellant worked with 

tendinitis in her right shoulder and that she experienced pain by the end of her workday. He 

reported examination findings and assessed her as having work-related right shoulder tendinitis.

Dr. Harden advised that appellant could continue to work with restrictions. 

In a report dated March 19, 2018, Dr. Erik T. McGoldrick, an orthopedic surgeon, related

that appellant presented for evaluation of her right shoulder pain since the September 2017

employment incident. He noted her history and findings on physical and x-ray examination. 

Dr. McGoldrick assessed appellant as having a partial tear of the rotator cuff. He was suspicious 

that she had subluxed her shoulder while pushing a crate last year as her left shoulder subluxed on 

an O’Brien’s test during his examination.

Following a telephonic hearing, held on May 22, 2018, OWCP, on June 4, 2018, received 

a letter and an after visit summary dated May 22, 2018 by Dr. Malia L. Honda, an internist. In the 

letter, Dr. Honda noted that appellant had a right shoulder injury. She listed work restrictions until 

further notice. In the after visit summary, Dr. Honda provided instructions for the care of 

appellant’s diagnosis of chronic right shoulder pain. 

Dr. Harden, in a duty status report (Form CA-17) dated December 11, 2017, noted a history 

of the accepted September 28, 2017 employment incident and described clinical findings. He 

diagnosed right shoulder tendinitis due to injury. Dr. Harden indicated that appellant could 

perform her regular full-time work with restrictions. On January 16, 2018 he referred her to

Dr. Raymond A. Koch, a Board-certified orthopedic surgeon, for a consultation regarding her right 

shoulder tendinitis. A February 13, 2018 medical bill by Dr. Harden indicated that appellant had 

an additional diagnosis of right shoulder internal derangement. 

Reports dated February 19 through April 3, 2018 from appellant’s physical therapist,

addressed the treatment of her diagnosed right shoulder conditions. 

In an additional report dated March 19, 2018, Dr. McGoldrick diagnosed right shoulder 

posterior labral tear and right shoulder ligamentous laxity. 

In an April 19, 2018 letter, Ellen Taylor, a certified physician assistant, indicated that 

appellant was doing very well with her work restrictions and recommended that these restrictions 

be continued. 

On April 30, 2018 Dr. McGoldrick again examined appellant and reiterated his assessment 

of partial tear of the rotator cuff and ordered an MRI scan arthrogram of her right shoulder to 

evaluate her partial tear of the rotator cuff. 
5

The findings of a June 1, 2018 right shoulder MRI scan arthrogram by Dr. James B. Moore, 

a Board-certified diagnostic radiologist, contained an impression of normal right shoulder. There 

were no signs of a rotator cuff tear, partial or full-thickness, and no labral abnormality. 

A right shoulder x-ray report dated June 1, 2018 by Dr. Stephen L. Viltrakis, a Boardcertified diagnostic radiologist, provided an impression of uncomplicated percutaneous right 

shoulder arthrocentesis for injection of gadolinium into the joint space. 

A report dated June 18, 2018 by Dr. McGoldrick noted appellant’s history, reviewed 

diagnostic test results, and discussed findings on physical examination. Appellant was assessed 

as having right shoulder subluxation. She could continue to perform modified work up to a 

maximum of five hours a day, five days a week.

By decision dated August 2, 2018, an OWCP hearing representative affirmed the 

November 20, 2017 decision, finding that the medical evidence of record was insufficient to 

establish the claim as it did not contain a rationalized physician’s opinion explaining how 

appellant’s medical condition was caused or aggravated by the accepted September 28, 2017 

employment incident. 

LEGAL PRECEDENT

An employee seeking benefits under FECA4 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 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 is causally related to the 

employment injury.5 These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated on a traumatic injury or an occupational disease.6

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 he or 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.7 

Rationalized medical opinion evidence is 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 

 

4 Supra note 2.

5 C.S., Docket No. 08-1585 (issued March 3, 2009); Elaine Pendleton, 40 ECAB 1143 (1989).

6 S.P., 59 ECAB 184 (2007); Victor J. Woodhams, 41 ECAB 345 (1989); Joe D. Cameron, 41 ECAB 153 (1989).

7

John J. Carlone, 41 ECAB 354 (1989); see 5 U.S.C. § 8101(5) (injury defined); 20 C.F.R. §§ 10.5(ee), 10.5(q) 

(traumatic injury and occupational disease defined, respectively). 
6

nature of the relationship between the diagnosed condition and the specific employment incident

identified by the claimant.8

ANALYSIS

The Board finds that appellant has not met her burden of proof to establish back and right 

shoulder conditions causally related to the accepted September 28, 2017 employment incident.

Dr. Harden’s January 15, 2018 progress report found that appellant had work-related right 

shoulder tendinitis and that she could continue to work with restrictions. However, he did not 

provide an explanation or rationale as to how the accepted September 28, 2017 employment 

incident caused or aggravated her diagnosed condition and work restrictions. The Board has held 

that a report is of limited probative value regarding causal relationship if it does not contain 

medical rationale explaining how a given medical condition/disability was related to employment 

factors.9 Likewise, Dr. Harden’s October 16, 2017 report which ordered appellant off work 

through November 15, 2017 due to work-related injuries, and his December 11, 2017 Form CA17 report which found that she had right shoulder tendinitis due to the September 28, 2017 

employment incident, also failed to offer medical rationale explaining how her right shoulder 

condition and resultant disability were causally related to the accepted employment incident.10 

The remaining reports, prescriptions, and the medical bill from Dr. Harden are of limited probative 

value with regard to establishing causal relationship as they do not provide a rationalized medical 

opinion establishing that her diagnosed right shoulder conditions and work restrictions were 

caused or aggravated by the accepted employment incident.11 The Board has held that medical 

evidence that does not offer an opinion regarding the cause of an employee’s condition is of no 

probative value on the issue of causal relationship.12 For the reasons stated, the Board finds that

Dr. Harden’s reports and prescriptions are insufficient to establish appellant’s burden of proof. 

Dr. McGoldrick’s March 19, 2018 report noted a history that appellant had experienced 

right shoulder pain since the September 28, 2017 employment incident. He assessed her as having 

a partial tear of the rotator cuff. Dr. McGoldrick related that he was suspicious that appellant had 

subluxed her shoulder while pushing a crate last year because her left shoulder subluxed on an 

O’Brien’s test during his examination. The Board notes that he did not definitively relate 

appellant’s diagnosed medical condition to the accepted September 28, 2017 employment 

incident. Dr. McGoldrick’s opinion on causation was highly speculative and couched in equivocal 

terms. To be of probative value, a physician’s opinion on causal relationship should be one of 

 

8

I.J., 59 ECAB 408 (2008); Victor J. Woodhams, supra note 6.

9 See A.J., Docket No. 18-1116 (issued January 23, 2019); Y.D., Docket No. 16-1896 (issued February 10, 2017) 

(finding that a report is of limited probative value regarding causal relationship if it does not contain medical rationale 

describing the relation between work factors and a diagnosed condition/disability).

10 Id.

11 See S.W., Docket No. 18-0721 (issued November 6, 2018).

12 See L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., Docket No. 17-1549 (issued July 6, 2018).
7

reasonable medical certainty.13 In his remaining reports, Dr. McGoldrick reiterated his assessment 

of partial tear of the rotator cuff and also diagnosed right shoulder posterior labral tear and right 

shoulder ligamentous laxity. However, he did not provide an opinion that the diagnosed right 

shoulder conditions were caused or aggravated by the accepted employment incident.14 For the 

reasons stated, the Board finds that Dr. McGoldrick’s reports are insufficient to meet appellant’s 

burden of proof.

Dr. Yandell’s October 9, 2017 patient visit information form and emergency department 

report diagnosed neck sprain or strain and upper back strain and found that appellant could work 

without restrictions. However, she did not offer a medical opinion addressing causal relationship 

between the diagnosed conditions and the September 28, 2017 employment incident. The Board 

finds, therefore, that Dr. Yandell’s reports are of no probative value and are insufficient to establish 

appellant’s claim.

15

Dr. Honda, in a May 22, 2018 report, noted that appellant had a right shoulder injury and 

listed her work restrictions until further notice, but she neither offered diagnosis nor an opinion on

causal relationship. As such, her report is of no probative value.16 The Board notes that, in her

May 22, 2018 after visit summary, Dr. Honda failed to provide a firm medical diagnosis as she 

only diagnosed chronic right shoulder pain. The Board has consistently held that pain is a 

symptom, not a compensable medical diagnosis.17 Thus, for the reasons stated, the Board finds 

that Dr. Honda’s reports are insufficient to establish appellant’s claim. 

Dr. Sonneland’s September 19, 2017 progress report predates the September 28, 2017 

pulling incident, and thus, is not relevant to the issue of whether the accepted employment incident 

caused or contributed to appellant’s right shoulder condition.18

Further, the diagnostic studies of record from Drs. Sharma, Attoun, Moore, and Viltrakis

lack probative value as they do not provide an opinion on causal relationship between the accepted 

employment factors and a diagnosed condition.19 

The reports from physician assistants and a physical therapist have no probative medical 

value in establishing appellant’s claim. Such healthcare providers are not considered 

 

13 See S.G., Docket No. 18-1373 (issued February 12, 2019); Beverly R. Jones, 55 ECAB 411 (2004).

14 See supra note 12.

15 Id. 

16 Id.

17 See M.V., Docket No. 18-1141 (issued January 3, 2019); B.B., Docket No. 18-1036 (issued December 31, 2018); 

K.V., Docket No. 18-0723 (issued November 9, 2018).

18 See S.L., Docket No. 16-0222 (issued August 1, 2016); S.L., Docket No. 12-0315 (issued June 8, 2012).

19 See C.F., Docket No. 18-1156 (issued January 22, 2019); S.G., Docket No. 17-1054 (issued September 14, 2017).
8

“physician[s]” as defined under FECA.20 Consequently, their medical findings and/or opinions

will not suffice for purposes of establishing entitlement to FECA benefits.21

Appellant failed to submit a rationalized opinion from a qualified physician relating her 

conditions to the accepted September 28, 2017 employment incident.22 Thus, she has not met her 

burden of proof to establish that she sustained back and right shoulder conditions causally related 

to the accepted September 28, 2017 employment incident.

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 her burden of proof to establish back and right 

shoulder conditions causally related to the accepted September 28, 2017 employment incident.

 

20 5 U.S.C. § 8101(2). This subsection defines a physician as surgeons, podiatrist, dentists, clinical psychologists, 

optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by State law.

21 K.W., 59 ECAB 271, 279 (2007); David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006). Federal (FECA) Procedure 

Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3a(1) (January 2013); see M.F., Docket No. 17-1973 

(issued December 31, 2018).

22 See C.S., Docket No. 17-1267 (issued December 18, 2017); G.H., Docket No. 17-1387 (issued October 24, 2017).
9

ORDER

IT IS HEREBY ORDERED THAT the August 2, 2018 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: April 18, 2019

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