United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

D.W., Appellant

and

DEPARTMENT OF DEFENSE, DEFENSE 

COMMISSARY AGENCY, 

MCGUIRE AIR FORCE BASE, NJ, Employer

__________________________________________

)

)

)

)

)

)

)

)

)

Docket No. 17-1884

Issued: November 8, 2018

Appearances: Case Submitted on the Record

Thomas R. Uliase, Esq., for the appellant1

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Chief Judge

PATRICIA H. FITZGERALD, Deputy Chief Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On September 6, 2017 appellant, through counsel, filed a timely appeal from an April 25, 

2017 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.3

 

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.

3 The record provided to the Board includes evidence received after OWCP issued its April 25, 2017 decision. The 

Board’s jurisdiction is limited to the evidence that was in the case record at the time of OWCP’s final decision. 

Therefore, the Board is precluded from reviewing this additional evidence for the first time on appeal. 20 C.F.R. 

§ 501.2(c)(1).
2

ISSUE

The issue is whether appellant has met her burden of proof to establish that she developed 

bilateral carpal tunnel syndrome causally related to the accepted factors of her federal employment.

FACTUAL HISTORY

This case has previously been before the Board.

4

 The facts and circumstances as set forth 

in the Board’s prior decision are incorporated herein by reference. The relevant facts are as 

follows.

On September 27, 2012 appellant, then a 51-year-old sales associate/cashier, filed an 

occupational disease claim (Form CA-2) alleging that she developed carpal tunnel syndrome in 

the performance of duty on or about February 10, 2010. She explained that her sales associate 

position entailed lifting food items of various weights, such as canned goods; uncooked meats;

gallons of milk, juice, and soda; animal food; and cat litter “10 [to] 50 lbs.”

In a note dated October 17, 2012, Dr. Raymond Ragland, III, a Board-certified orthopedic 

hand surgeon, diagnosed bilateral carpal tunnel syndrome. On physical examination he noted 

positive bilateral results for Tinel’s sign and direct compression. Dr. Ragland reported that, to a 

reasonable degree of medical certainty, appellant’s bilateral carpal tunnel syndrome symptoms 

were work-related processes. He recommended an open right carpal tunnel release procedure.

Appellant’s diagnoses included right de Quervain’s tenosynovitis, left trigger thumb, and 

bilateral carpal tunnel syndrome. On November 9, 2012 Dr. Ragland performed an endoscopic 

right carpal tunnel release.

By decision dated December 31, 2012, OWCP denied appellant’s occupational disease 

claim, finding that the evidence of record was insufficient to establish that the claimed events(s) 

occurred as described. It further found that she had not established that her bilateral carpal tunnel 

syndrome was causally related to her federal employment duties.

In a note dated April 18, 2013, Dr. Ragland indicated that appellant had clinical and 

neurometric findings consistent with bilateral carpal tunnel syndrome. He added that, in reviewing 

her history, clinical findings, and neurometric findings, her bilateral carpal tunnel syndrome was 

a work-related process, and that this opinion was rendered within a reasonable degree of medical 

certainty.

By decision dated June 12, 2013, a representative of OWCP’s Branch of Hearings and 

Review modified the December 31, 2012 decision to find that appellant had established that the 

claimed events occurred as alleged. However, the hearing representative affirmed the denial of 

benefits, finding that the medical evidence of record was insufficient to establish causal 

relationship between her diagnosed upper extremity conditions and the accepted work factors of 

“lifting items, scanning items, and keying data into the register.”

 

4 Docket No. 13-1873 (issued March 13, 2014).
3

By decision dated March 13, 2014, the Board affirmed the hearing representative’s 

June 12, 2013 decision. The Board found that the reports of Dr. Ragland were insufficient to 

establish that appellant’s bilateral carpal tunnel syndrome was work related. The Board also found 

that a July 25, 2012 form report from Dr. Daniel K. Mullin, a Board-certified emergency medicine 

specialist, was insufficient to establish causal relationship.5 Lastly, the Board rejected counsel’s 

argument that appellant had established a prima facie case, thereby, warranting further medical 

development by OWCP.6

On March 13, 2015 counsel timely requested reconsideration. He submitted a 

September 5, 2013 left upper extremity electromyogram and nerve conduction velocity 

(EMG/NCV) study that revealed evidence of moderate left median nerve neuropathy consistent 

with a clinical diagnosis of carpal tunnel syndrome.

In a March 24, 2015 report, Dr. Ragland reviewed his treatment of appellant dating back 

to May 2011, including the surgery he performed on November 9, 2012, and her postoperative 

care through December 21, 2012. He noted that, after a long absence, she returned on February 11, 

2015 at which time she presented with persistent left carpal tunnel syndrome symptoms. 

Examination of the left hand revealed normal range of motion with positive tests for Tinel’s sign, 

Phalen’s test, and a median nerve compression test. There was diminished sensation in the thumb, 

index, and middle fingers. An EMG was performed and Dr. Ragland recommended a left carpal 

tunnel release. Dr. Ragland noted that he reviewed appellant’s medical records as well as her job 

description. He noted that she was a cashier who, on occasion, had been required to lift heavy 

items between 25 and 60 pounds. Dr. Ragland observed, “The repetitive stress nature of 

[appellant’s] job has most certainly been an aggravating factor, if not a causative factor, in her 

current complaints of left carpal tunnel syndrome pain. He explained that the medical literature 

supports repetitive stress injury as an aggravating or causative factor of carpal tunnel syndrome in 

the workplace setting. Dr. Ragland also found noteworthy the fact that appellant had no 

complaints of carpal tunnel syndrome symptoms prior to her current job. He concluded that, to a 

reasonable degree of medical certainty, appellant’s current left carpal tunnel syndrome complaints 

were work related. Dr. Ragland reiterated that in light of her continued discomfort and 

dysfunction, left carpal tunnel release was recommended.

By decision dated June 9, 2015, OWCP reviewed the merits of appellant’s case, but denied 

modification of its December 31, 2012 decision. It found that Dr. Ragland’s report of March 24, 

2015 was insufficient to establish the claim because he did not note how often she performed any 

specific duties of her federal employment or how those work factors had caused or aggravated her 

diagnosed condition. OWCP noted that he had not demonstrated a thorough understanding of 

appellant’s duties, as he did not explain what “repetitive stress” he was referring to.

OWCP subsequently received additional treatment records from Dr. Ragland dated 

between February 11 and September 2, 2015, including a June 16, 2015 operative report. On 

 

5 Dr. Mullin reported that appellant sustained an overuse injury requiring follow-up with a hand surgeon. He 

indicated by checkmark that the injury “was incurred in line of duty.”

6

Id.
4

June 16, 2015 Dr. Ragland performed a left carpal tunnel release on appellant’s left upper 

extremity, which was completed without complications.

By letter dated September 17, 2015, Dr. Ragland observed that appellant had persistent 

bilateral carpal tunnel syndrome symptoms, which were “most certainly a work-related process.” 

He reviewed her responsibilities at work, including significant repetitive activities such as cash 

register keying, merchandise scanning, and intermittent lifting of heavy items at work. 

Dr. Ragland explained that these activities had caused a significant worsening of her symptoms 

overtime, requiring multiple bilateral carpal tunnel injections and therapy. He concluded, “To a 

reasonable degree of medical certainty, the patient’s bilateral carpal tunnel syndrome symptoms 

are work related.”

On March 11, 2016 counsel requested reconsideration of OWCP’s June 9, 2015 decision. 

He referenced Dr. Ragland’s September 17, 2015 letter, as well as his treatment records.

By decision dated July 15, 2016, OWCP reviewed the merits of appellant’s case and denied 

modification of its June 9, 2015 decision. It found that, while Dr. Ragland had opined as to the 

causal relationship between her bilateral carpal tunnel syndrome and specific duties of her federal 

employment, his opinion was insufficient to establish causal relationship because he did not 

explain how cash register keying, merchandise scanning, and lifting of heavy items at work 

directly caused or aggravated her carpal tunnel syndrome. OWCP further noted that he should 

also explore and consider nonwork-related factors when providing an explanation on causal 

relationship. 

On October 17, 2016 appellant, through counsel, requested reconsideration of OWCP’s 

July 15, 2016 decision. Attached to the request was a September 16, 2016 report from

Dr. Ragland. Dr. Ragland reported that appellant had bilateral carpal tunnel syndrome, with a 

history of bilateral carpal tunnel release surgery and a revision procedure on the left. He noted 

persistent burning pain and weakness in both hands despite conservative and surgical treatment. 

Dr. Ragland further reported that appellant’s carpal tunnel syndrome symptoms were related to 

her prior employment as a cashier, noting that in prior correspondence, he had delineated her 

subjective and objective findings consistent with the diagnosis of bilateral carpal tunnel syndrome. 

He cited three medical journal articles regarding carpal tunnel syndrome. Dr. Ragland explained, 

“A review of her job history shows relevant exposure risk with regard to significant intermittent 

peak hand force use, forceful hand repetition rates and percentage of time in forceful hand 

exertions.” He noted that these factors were clinically significant risks in the development of 

carpal tunnel syndrome. 

December 7, 2016 EMG/NCV studies revealed bilateral median nerve impairments at the 

wrists, moderate at the right and mild on the left. The EMG/NCV studies further revealed severe 

left bilateral ulnar nerve impairment and significant right bilateral ulnar nerve impairment, as well 

as moderate right posterior interosseous nerve impairment at the dorsal elbow/radial tunnel level.

By decision dated December 20, 2016, OWCP reviewed the merits of appellant’s case, but

denied modification of its July 15, 2016 decision. It found that Dr. Ragland’s September 16, 2016 

report was insufficient to establish her claim because, although he included her job history and 

described forceful hand use, exertion, and repetition, he did not describe her specific work factors 

or provide a rationalized medical opinion as to how the work factors directly caused or aggravated 
5

her condition. OWCP further noted that he had provided medical studies to support his opinion

and that these studies were of no evidentiary value in establishing causal relationship, because they 

were of general application.

In a report dated October 26, 2016, Dr. Scott M. Fried, an osteopath and Board-certified 

orthopedic surgeon, reviewed appellant’s list of duties, noting regular keying and scanning on a 

register, lifting and carrying, handling of groceries, and lifting of large bags. He noted that, prior 

to February 10, 2010, she had no problems, but that on or about that date she began developing 

progressive problems in her hands, including numbness and tingling. Dr. Fried reviewed 

appellant’s medical history with Dr. Ragland, including her surgery for her right carpal tunnel 

syndrome in 2012 and for her left carpal tunnel syndrome on June 16, 2015. He examined her, 

finding positive tests for carpal tunnel syndrome bilaterally. Dr. Fried opined that there is “no 

doubt a direct cause and effect relationship between this patient’s work activities and the current 

clinical complaints and physical manifestations of these injuries.” He explained the general causes 

of her condition, including repeated stress and strain on the flexor tendons and her prognosis, 

recommending continued treatment. 

In a functional capacity evaluation (FCE) dated November 29, 2016, Dr. Fried noted that 

appellant was employed as a military cashier and had sustained repetitive strain injuries to her 

upper extremities resulting in right radial neuropathy, bilateral medium neuropathy, brachial 

plexopathy, and right cervical radiculopathy while at work. He reviewed her history of treatment 

with Dr. Ragland and noted that she had not worked since shortly after her first carpal tunnel 

surgery. Dr. Fried performed a hand function evaluation, administration of standardized tests, and 

observation of performance of physical demands with job simulation. He concluded that appellant 

was unable to perform repetitive activities including simple grasping, fine manipulation, firm 

grasping, pushing/pulling, or overhead/shoulder-level reaching with her upper extremities. 

Dr. Fried noted that she was unable to lift more than two pounds or carry more than one pound of 

weight without complaining of nerve symptoms.

On December 23, 2016 Dr. Fried reviewed the FCE of November 29, 2016. He noted that 

appellant had increased symptoms with work simulation activities, diminished ability to 

manipulate small objects, and increased symptoms with lifting and carrying activity. Appellant 

was able to write for 2.75 minutes and key for 1 minute before exacerbating her symptoms. 

Dr. Fried noted that these should be considered permanent limits.

On January 30, 2017 appellant, through counsel, requested reconsideration of OWCP’s

December 20, 2016 decision. He argued that Dr. Fried’s November 29, 2016 FCE, read together 

with diagnostic tests and the previous reports of Dr. Ragland, provided sufficient medical evidence 

to establish her claim for bilateral carpal tunnel syndrome. Counsel further argued that there 

existed at least prima facie evidence of appellant’s claimed occupational disease. 

By decision dated April 25, 2017, OWCP reviewed the merits of appellant’s case, but

denied modification of its December 20, 2016 decision. It found that Dr. Fried’s October 26, 2016 

report did not sufficiently explain how her diagnosed conditions were caused or aggravated by 

factors of her federal employment. As such, it was insufficient to establish appellant’s claim. 
6

LEGAL PRECEDENT

A claimant seeking benefits under FECA7 has the burden of proof to establish the essential 

elements of his or her claim by the weight of the reliable, probative, and substantial evidence, 

including that an injury was sustained in the performance of duty as alleged and that any specific 

condition or disability claimed is causally related to the employment injury.8

To establish that an injury was sustained in the performance of duty in an occupational 

disease claim, a claimant must submit: (1) medical evidence establishing the presence or existence 

of the disease or condition for which compensation is claimed; (2) a factual statement identifying 

employment factors alleged to have caused or contributed to the presence or occurrence of the 

disease or condition; and (3) medical evidence establishing that the diagnosed condition is causally 

related to the identified employment factors.9

Causal relationship is a medical question, which generally requires rationalized medical 

opinion evidence to resolve the issue.10 A physician’s opinion on whether there is a causal 

relationship between the diagnosed condition and the implicated employment factors must be 

based on a complete factual and medical background.11 Additionally, the physician’s opinion must 

be expressed in terms of a reasonable degree of medical certainty, and must be supported by 

medical rationale, explaining the nature of the relationship between the diagnosed condition and 

appellant’s specific employment factors.12

ANALYSIS

The Board finds that this case is not in posture for decision.13

The record contains medical reports from Dr. Ragland dated March 24, 2015; 

September 17, 2015; and September 16, 2016, as well as a report from Dr. Fried dated 

October 26, 2016.

14

 In his report dated March 24, 2015, Dr. Ragland indicated that he first treated 

appellant on May 6, 2011 for with complaints of discomfort of the radial aspect of her right wrist, 

 

7 Supra note 2.

8 20 C.F.R. § 10.115(e), (f); see Jacquelyn L. Oliver, 48 ECAB 232, 235-36 (1996).

9 Victor J. Woodhams, 41 ECAB 345, 352 (1989).

10 See Robert G. Morris, 48 ECAB 238 (1996). 

11 Supra note 8.

12 Id.

13 See E.B., Docket No. 17-1909 (issued March 16, 2018).

14 With regard to the reports of Dr. Ragland and other medical evidence the Board notes that it is unnecessary for 

the Board to consider the evidence appellant submitted prior to the issuance of OWCP’s June 9, 2015 decision because 

the Board has already considered this evidence in its March 13, 2014 decision and found that it failed to establish that 

she developed bilateral carpal tunnel syndrome causally related to factors of her federal employment. Findings made 

in prior Board decisions are res judicata absent further review by OWCP under section 8128(a) of FECA. See A.C., 

Docket No. 18-0484 (issued September 7, 2018).
7

with intermittent parasthesias in the median nerve distribution of the right hand, and saw her again 

on additional occasions. He noted that she had no prior complaints of carpal tunnel syndrome 

symptoms prior to her current place of employment at her current job. Dr. Ragland reviewed 

specific appellant’s duties of her federal employment in his report of September 17, 2015 and 

opined that these duties had caused or aggravated her bilateral carpal tunnel syndrome within a 

reasonable degree of medical certainty. He also reviewed test results demonstrating positive 

testing for symptoms of bilateral carpal tunnel syndrome, as well as her medical history. On 

October 17, 2016 Dr. Ragland explained how specific movements related to appellant’s duties had 

caused or aggravated her bilateral carpal tunnel syndrome, writing, “A review of [appellant’s] job 

history shows relevant exposure risk with regard to significant intermittent peak hand force use, 

forceful hand repetition rates and percentage of time in forceful hand exertions.” Dr. Fried’s 

medical report of October 26, 2016 concurred with Dr. Ragland’s opinion that her condition had 

been caused by specific factors of her federal employment.

Dr. Ragland and Dr. Fried provided affirmative opinions on causal relationship. They 

accurately identified specific employment factors to which appellant claimed caused her condition

and identified findings on examination. 

The Board notes that, while none of the reports of appellant’s attending physicians is 

completely rationalized, they are consistent in indicating that she sustained an employment-related 

wrist condition and are not contradicted by any substantial medical or factual evidence of record. 

While the reports are insufficient to meet her burden of proof to establish her claim, they raise an 

uncontroverted inference between her wrist condition and the identified employment factors and 

are sufficient to require OWCP to further develop the medical evidence and the case record.15

The Board finds that the March 24 and September 17, 2015, and September 16, 2016 

reports of Dr. Ragland, considered together with the report of Dr. Fried are sufficient, given the 

absence of any opposing medical evidence, to require further development of the record.16

It is well established that proceedings under FECA are not adversarial in nature, nor is 

OWCP a disinterested arbiter. While the claimant has the burden of proof to establish entitlement 

to compensation, OWCP shares the responsibility in the development of the evidence to see that 

justice is done.17 The case shall, therefore, be remanded to OWCP. On remand, it shall refer 

appellant, a statement of accepted facts, and the medical evidence of record to an appropriate 

Board-certified specialist for an examination, diagnosis, and a rationalized opinion as to whether 

she sustained an employment-related occupational disease. After this and other such further 

development deemed necessary, OWCP shall issue a de novo decision.

CONCLUSION

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

 

15 E.J., Docket No. 09-1481 (issued February 19, 2010); see also John J. Carlone, 41 ECAB 354, 360 (1989).

16 See A.F., Docket No. 15-1687 (issued June 9, 2016); Id. 

17 D.G., Docket No. 15-0702 (issued August 27, 2015); Donald R. Gervasi, 57 ECAB 281, 286 (2005); William J. 

Cantrell, 34 ECAB 1233, 1237 (1983).
8

ORDER

IT IS HEREBY ORDERED THAT the April 25, 2017 decision of the Office of Workers’

Compensation Programs is set aside and the case is remanded to OWCP for proceedings consistent 

with this opinion of the Board.

Issued: November 8, 2018

Washington, DC

Christopher J. Godfrey, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Deputy Chief Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board