United States Department of Labor 

Employees’ Compensation Appeals Board 

_________________________________________ 

D.J., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Bedford Park, IL, Employer 

___________________________________________

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Docket No. 16-0965 

Issued: October 5, 2016 

Appearances: Case Submitted on the Record 

Appellant, pro se

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

COLLEEN DUFFY KIKO, Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On April 6, 2016 appellant filed a timely appeal of a March 24, 2016 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 a traumatic injury 

causally related to a May 15, 2015 employment incident. 

FACTUAL HISTORY 

On June 5, 2015 appellant, then a 52-year-old city carrier assistant, filed a traumatic 

injury claim (Form CA-1) alleging that on May 15, 2015 she injured her left foot when she 

stepped on a rock, which caused a painful lump in her left foot, in the performance of duty. She 

 1

 5 U.S.C. § 8101 et seq.
2

did not initially stop work. The employing establishment indicated that appellant “never 

mentioned walking on a rock prior to the initial reporting of the incident.” It was noted that she 

“only mentioned from time to time that her foot was bothering her.” 

In a June 5, 2015 statement, appellant indicated that, on or around May 15, 2015, she was 

on her route when she stepped on a large rock. She advised that, a few days later, she noticed a 

lump under her foot. Appellant related that it hurt the more she walked. She indicated that on 

May 27, 2015 she went to the urgent care center and was placed off work as her foot was hurting 

and swollen. Appellant noted that on June 5, 2015 the pain intensified the more she walked. 

On May 26, 2015 Dr. Steven Lubera, an emergency medicine physician, treated appellant 

for left foot pain and swelling. 

By letter dated November 19, 2015, OWCP noted that appellant’s claim initially 

appeared to be a minor injury that resulted in minimal or no lost time from work and was 

administratively handled to allow a limited amount of medical payments. However, appellant’s 

claim was now being reopened for formal adjudication. OWCP informed her of the type of 

evidence needed to support her claim and afforded her 30 days to submit such evidence. 

In a June 24, 2015 treatment note, Dr. Robert Sheffey, a podiatrist, noted that appellant 

presented with complaints of pain in the left forefoot. He advised that she had stepped on a rock 

while at work on May 5, 2015, shortly began experiencing pain, and noticed a lump on the 

bottom of her foot which remained painful and swollen. Dr. Sheffey indicated that it became 

more pronounced with activity. He related that appellant had been informed that she had plantar 

fasciitis and was told to follow up with a physician. Dr. Sheffey explained that she tried ice and 

heat with no alleviation of symptoms. On examination, appellant had pain on palpation at the 

second metatarsophalangeal joint of the left foot, moderate pain on palpation of the second 

interspace left, moderate discomfort on range of motion at the second metatarsophalangeal joint, 

and edema at the plantar aspect of the left forefoot centrally located at the second metatarsal 

phalangeal joint. Dr. Sheffey diagnosed enthesopathy, limb pain, and edema. He reviewed 

x-rays and explained that appellant appeared to be suffering from capsulitis of the second 

metatarsophalangeal joint of the left foot. Dr. Sheffey opined that her injury was consistent with 

stepping on a rock. He noted that the pain was present since the first time of stepping on a rock 

while at work. Dr. Sheffey placed appellant off work for four weeks. 

In a July 25, 2015 treatment note, Dr. Sheffey reported that appellant presented for 

continued treatment for capsulitis of the second metatarsophalangeal joint of the left foot. 

Appellant continued to have discomfort, but was much improved. Dr. Sheffey diagnosed 

dermatophytosis of nail, plantar fascial fibromatosis, enthesopathy, plantar nerve lesion, limb 

pain, edema, hammer toe, and hallux valgus. He administered ultrasound therapy and electrical 

stimulation to the left foot along with strapping bilaterally to off-load metatarsal heads. 

Dr. Sheffey applied an “Unnas boot compressive wrap” to control swelling. He indicated that 

appellant would return to work on Monday and that she could remove the wrappings at that 

point. Dr. Sheffey explained that, if her condition did not resolve, a bunionectomy and 

hammertoe correction might be needed. 
3

On November 25, 2015 Dr. Sheffey noted, in an attending physician’s report the history 

of appellant stepping on a rock and sustaining an injury to her left foot. He checked the box 

marked “yes” in response to whether she had a history of “concurrent or preexisting injury or 

disease” and described the injury as “hallux valgus and hammer toes.” Dr. Sheffey advised that 

x-rays revealed capsulitis with hallux valgus and hammer toes. He diagnosed capsulitis on the 

second metatarsophalangeal joint. Dr. Sheffey checked the box marked “yes” in response to 

whether he believed that the condition was caused or aggravated by an employment activity. He 

explained that the second metatarsophalangeal joint was injured and remained painful due to the 

work incident and appellant remained disabled. Dr. Sheffey also completed a duty status report 

of the same date advising that she remained disabled for work. 

Appellant explained, in a November 24, 2015 statement that, on May 12, 2015 while 

delivering mail, she stepped on a large piece of broken concrete, that her foot started to hurt, but 

that she kept working. She noted that a few days later she noticed a lump in the middle of the 

foot on the bottom which was very painful and inflamed. Appellant advised that she began 

treatment with Dr. Sheffey. She also noted that she had been disciplined for failing to timely 

notify her supervisor of the incident on May 12, 2015.2

 

By decision dated December 28, 2015, OWCP denied appellant’s claim finding that the 

medical evidence failed to establish an injury causally related to the accepted May 15, 2015 work 

incident. 

On January 6, 2016 appellant requested reconsideration. She indicated that her claim was 

denied because she had a preexisting condition. Appellant advised that she was attaching new 

medical evidence that would clarify the details of her condition. 

In a January 6, 2016 report, Dr. Sheffey explained that he was providing rationale 

regarding appellant’s proposed surgery. He indicated that she had severe capsulitis of the second 

metatarsophalangeal joint. Dr. Sheffey noted that appellant had underlying progressive 

deformities that include a hallux valgus deformity and a hammer digit deformity of the second 

digit. He explained that either of these two “together or isolated may cause capsulitis or as in 

[appellant’s] case, prevent a capsulitis from healing.” Dr. Sheffey further noted that there was a 

high percentage of the population with one or two of the deformities and the “vast percentage 

never experience the condition of capsulitis. Prior to [appellant’s] injury she was not 

experiencing capsulitis.” Dr. Sheffey noted: 

“In my opinion [appellant] suffered an injury to the second metatarsophalangeal 

joint causing capsulitis or an inflammation of the second metatarsophalangeal 

joint. Due to the fact that she has underlying deformities of hammer digit 

syndrome and hallux valgus there is significant pressure at the second 

metatarsophalangeal joint, which is preventing this condition from healing. Were 

it not for these underlying deformities I am confident that conservative treatment 

 2

 On November 21, 2015 appellant claimed a recurrence of disability on November 18, 2015 due to her claimed 

May 12, 2015 injury. She advised that she stopped work on November 21, 2015. In a December 8, 2015 letter, 

OWCP advised appellant that she had not experienced a recurrence under FECA because her initial claim had not 

been accepted. 
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would have ultimately been successful in resolving [appellant’s] symptoms. 

Conservative treatment on [appellant] has been exhausted and unfortunately, she 

continues to experience pain that in my opinion is due [to] the fact that these 

underlying deformities are impeding her ability [to] heal due to increased pressure 

at the second metatarsophalangeal joint. At this point in order to resolve [her] 

painful capsulitis which, was initiated by her work injury ... I believe [that] the 

deformities need to be corrected to decrease the pressure at the second 

metatarsophalangeal joint and allow her foot to heal. Failure to surgically correct 

these deformities [will] likely result in continued pain for this patient.” 

In a February 24, 2016 statement of accepted facts (SOAF), OWCP noted that appellant 

continued to work until July 6, 2015. Appellant then worked one hour per day from July 6 to 15, 

2015 and four hours per day from July 20, 2015. Thereafter, she returned to work full duty on 

July 28, 2015 and stopped work again on November 21, 2015. 

On February 24, 2016 OWCP requested that an OWCP medical adviser review the record 

and the SOAF and thereafter address whether appellant’s condition of capsulitis of the second 

metatarsophalangeal joint was work related. It also requested an opinion with regard to the 

requested surgery from Dr. Sheffey. OWCP advised that the claim had not been accepted. 

In a March 7, 2016 report, OWCP medical adviser noted appellant’s history of injury and 

treatment along with the SOAF. He found that the proposed surgery to correct the deformities 

was causally related to the accepted medical condition as there was a temporal relationship 

between the industrial injury of May 15, 2015 and the proposed surgery. The medical adviser 

found however that the treating physician had failed to support his diagnosis of hammertoe 

syndrome with evidence of radiographs demonstrating the degree of hammertoe and had failed to 

explain the conservative treatment he had ordered. He further opined that there was no medical 

evidence to support capsulitis of the left foot. The medical adviser explained that capsulitis was 

normally diagnosed with a magnetic resonance imaging (MRI) scan of the foot, which was not 

present in this case. He related that the treating physician had not explained what imaging 

modality was used to diagnose severe capsulitis of the foot. The medical adviser concluded that 

the medical evidence was insufficient to support that the capsulitis of the left foot was medically 

connected to the injury of May 15, 2015. 

By decision dated March 24, 2016, OWCP denied modification of the prior decision. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA 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 timely filed within the 

applicable time limitation period of FECA,3 and that an injury was sustained in the performance 

 3 Joe D. Cameron, 41 ECAB 153 (1989). 
5

of duty.4

 These are the essential elements of each 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 the fact of injury has been established. 

There are two components involved in establishing the 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.6 In some traumatic injury cases, this 

component can be established by an employee’s uncontroverted statement on the Form CA-1.7 

Second, the employee must submit sufficient evidence, generally only in the form of medical 

evidence, to establish that the employment incident caused a personal injury.8 

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.9

ANALYSIS 

Appellant has alleged that on May 15, 2015 she sustained an injury to her left foot in the 

performance of duty. The evidence supports that the claimed event occurred. Therefore, the 

Board finds that appellant stepped on a rock at work as alleged. 

However, with regard to the medical evidence, the Board finds the case not in posture for 

decision. Dr. Sheffey explained that appellant had severe capsulitis of the second metatarsophalangeal joint that required surgery. He determined that she had underlying progressive 

deformities to include a hallux valgus deformity and a hammer digit deformity of the second 

digit and opined that either of these two together or isolated could cause capsulitis or prevent a 

capsulitis from healing. Dr. Sheffey pointed out that prior to appellant’s injury, she had not 

experienced capsulitis. He opined that she had injured the second metatarsophalangeal joint 

causing capsulitis or an inflammation of the second metatarsophalangeal joint. Due to the fact 

that appellant also had preexisting underlying deformities of hammer digit syndrome and hallux 

valgus, there was significant pressure at the second metatarsophalangeal joint preventing the 

condition from healing. Dr. Sheffey explained that conservative treatment had been exhausted 

and that to resolve her painful capsulitis, surgery was indicated to decrease the pressure at the 

second metatarsophalangeal joint and allow appellant’s foot to heal. 

 4 James E. Chadden, Sr., 40 ECAB 312 (1988). 

5 Delores C. Ellyett, 41 ECAB 992 (1990). 

6 Julie B. Hawkins, 38 ECAB 393, 396 (1987). 

7 John J. Carlone, 41 ECAB 354 (1989). 

8 Id. For a definition of the term “traumatic injury,” see 20 C.F.R. § 10.5(ee). 

9 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 
6

On February 24, 2016 OWCP asked its medical adviser to review the matter. In a 

March 7, 2016 report, the medical adviser noted appellant’s history of injury and treatment along 

with the SOAF. Regarding the proposed surgery, he explained that the proposed surgery, to 

correct the deformities, was causally related to the accepted medical condition as there was a 

temporal relationship between the industrial injury of May 15, 2015 and the proposed surgery. 

The medical adviser found, however, that the proposed surgery to correct the deformities was not 

medically necessary as there was a lack of x-rays showing the degree of hammertoe or evidence 

showing failure of conservative management to justify surgery. In response to whether the 

capsulitis of the left foot was medically connected to the injury of May 15, 2015 he opined that 

there was no medical evidence to support capsulitis of the left foot. The medical adviser noted 

that an MRI scan was normally used to diagnose capsulitis, but there was no MRI scan present in 

this case. He related that it was unclear to him how the condition had been diagnosed as the 

treating physician had not identified the imaging method he had used. The medical adviser 

concluded that the medical evidence was therefore insufficient to support that the capsulitis of 

the left foot was medically connected to the injury of May 15, 2015. 

The Board finds that the medical adviser’s report is contradictory. Further, medical 

development is needed with regard to whether appellant has a diagnosed condition that was 

caused or aggravated by stepping on a rock on May 15, 2015. The medical adviser opined “yes” 

that the proposed surgery was causally related to an accepted medical condition, but “no” in 

response to whether the proposed surgery to correct the deformities was medically necessary. 

He also opined that the diagnosed adhesive capsulitis was not due to the May 15, 2015 work 

incident finding that there was no medical evidence to support that appellant had that condition 

due to a lack of diagnostic testing. The Board notes that, contrary to the medical adviser’s 

statement, no condition has been accepted by OWCP as employment related. Thus, the medical 

adviser’s opinion is of limited probative value as it is not based on an accurate factual 

background.10 Finally, he did not clearly explain why he suggested that surgery was warranted 

for a condition he deemed to be accepted while later opining that left foot capsulitis was not 

causally related to the work incident. Therefore, the Board finds that the case must be remanded 

for further development of the medical evidence and a reasoned opinion regarding whether 

appellant has a work-related condition to the employment incident and, if so, whether any such 

conditions necessitate surgery. 

Once OWCP undertakes development of the record, it has the responsibility to obtain an 

evaluation, which will resolve the issue involved in the case.11 The case is remanded to OWCP 

to refer appellant to an appropriate Board-certified specialist for a rationalized medical opinion 

on whether the May 15, 2015 work incident caused or aggravated a diagnosed left foot condition. 

Following such further development as deemed necessary, OWCP shall issue a de novo decision. 

CONCLUSION 

The Board finds that this case is not in posture for decision. 

 10 See Leonard J. O’Keefe, 14 ECAB 42, 48 (1962) (where the Board held that medical opinions based upon an 

incomplete history have little probative value). 

11 See Robert Kirby, 51 ECAB 474, 476 (2000); Mae Z. Hackett, 34 ECAB 1421 (1983). 
7

ORDER 

IT IS HEREBY ORDERED THAT the March 24, 2016 decision of the Office of 

Workers’ Compensation Programs is set aside and remanded. 

Issued: October 5, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board