United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

T.G., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Joshua Tree, CA, Employer

__________________________________________

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Docket No. 17-1840

Issued: December 20, 2018

Appearances: Case Submitted on the Record

Alan J. Shapiro, Esq., for the appellant1

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Chief Judge

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On August 29, 2017 appellant, through counsel, timely appealed from a July 27, 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.

 

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. § 810 et seq.
2

ISSUE

The issue is whether appellant has met her burden of proof to establish a left shoulder 

condition causally related to the accepted June 13, 2016 employment incident.

FACTUAL HISTORY

On June 13, 2016 appellant, then a 59 year-old clerk, filed a traumatic injury claim (Form 

CA-1) alleging that on that date she injured her left shoulder when she pushed a postal container

while in the performance of duty. She explained that it kept getting caught on the left and right 

side where workers had blocked one half of the door. Appellant did not initially stop work. The 

employing establishment responded, “no” with regard to whether their knowledge of the facts of 

this injury agreed with the statements of the employee and/or witness. The employing 

establishment responded that appellant complained of shoulder pain in the past. Additionally, it 

was noted that “a reenactment of the incident does not make sense as to how the left shoulder 

would have been injured.”

Appellant provided a separate statement dated June 14, 2016 in which she noted that she 

was not currently seeking medical attention for the incident of June 13, 2016, when she injured

her left shoulder.

OWCP received a report of accident/incident from EHS. The report noted that appellant 

indicated that she “was trying to push a wire lobster cage outside back door, it kept getting caught 

on the left and right side where workers had blocked one half of door.”

A June 20, 2016 left shoulder x-ray read by Dr. Michael Allen, a Board-certified internist, 

was normal. Dr. Allen noted that appellant was pushing a huge basket when she bumped into the 

door and hurt her left shoulder. He advised that it was work related and noted that she had blunt 

trauma and contusions or hematomas on the left shoulder.

In a report, initially received on June 29, 2016, Dr. Robert Evans, an internist, noted that 

appellant indicated that she was trying to push a postal container through an outer doorway that 

was blocked on one side. He indicated that her subjective complaints included pain in the left 

shoulder. Dr. Evans diagnosed left shoulder sprain. OWCP received an undated duty status report 

(Form CA-17) from Dr. Evans, who advised no regular work. In a June 20, 2016 duty status report,

Dr. Evans noted her history of injury and noted she had pain on the left shoulder. In June 27, 2016 

reports, he advised that appellant still had pain from the left shoulder. Dr. Evans completed a duty 

status report including work restrictions. In a July 4, 2016 progress report, he noted that 

appellant’s shoulder felt better from pain and diagnosed shoulder strain. Dr. Evans advised 

continuing modified work with limited use of the left arm. He continued to treat appellant and 

provided reports on July 11, 15, 18, and August 1, 9, 2016. In July 11 and August 15, 2016

disability certificates, Dr. Evans advised returning to work with restrictions.

OWCP also received a series of physical therapy reports from August 2016. In an 

August 2, 2016 physical therapy report, the physical therapist noted that appellant presented with 

a left shoulder strain following an incident at work on June 13, 2016. He noted that the x-ray was 

unremarkable. The physical therapist related that appellant claimed that the same incident had 
3

occurred in December 2015, but that she did not file an incident report at work. He noted that 

appellant explained that her son, an orthopedic surgeon, explained that she “probably tore 

something and needs surgery.” In an August 31, 2016 discharge report, the therapist diagnosed 

strain of other muscles, fascia, and tendons at the shoulder and upper arm level, unspecified arm 

and pain in the left shoulder. He advised that appellant was discharged as she had completed 

treatment.

By development letter dated September 23, 2016, OWCP advised appellant of the 

deficiencies in the evidence received. It requested that she complete a questionnaire and respond 

to factual questions regarding the prior injury in December 2015 and her son’s suggestion of 

surgery. OWCP also requested a narrative medical report from appellant’s physician, which 

should include: dates of examination and treatment; history and date of injury given by appellant 

to the physician; description of findings; results of x-rays and tests; a diagnosis and clinical course 

of treatment followed; and the physician’s opinion supported by a medical explanation as to how 

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

to provide the requested evidence.

OWCP received new evidence as well as copies of previously submitted reports.

In a September 13, 2016 duty status report, Dr. Evans repeated his description of how the 

incident occurred and diagnosed left shoulder strain. He noted that appellant was advised to 

resume modified work on September 13, 2016.

A September 21, 2016 magnetic resonance imaging (MRI) scan of the left shoulder read 

by Dr. John F. Feller, a diagnostic radiologist, revealed no evidence of full-thickness rotator cuff 

tear. Other findings included, but were not limited to a history of clinical syndrome of 

impingement including mild osteoarthritis involving the acromioclavicular joint; mild subacromial 

bursitis; and severe tendinosis throughout the supraspinatus tendon extending as moderate 

tendinosis along the articular surface of the infraspinatus tendon. Dr. Feller noted that the 

supraspinatus and the infraspinatus tendon pathology in part or in whole may be traumatic in 

etiology.

In an October 16, 2016 response to the questionnaire, appellant explained that her prior 

injury occurred on approximately December 20, 2015. She explained that the injury occurred 

when she was distributing packages to carrier routes. Appellant noted that she scanned the 

packages with her right hand while throwing them with her left. She explained that she threw one 

to route two’s hamper and felt a sharp pain in her left shoulder. Appellant assumed that she had 

strained a muscle and kept working. She noted that she did not receive medical treatment, but she 

did tell the postmaster about the incident when she arrived. Appellant also informed her son, an 

orthopedic surgeon, of this incident. She responded that, with regard to her son advising her that 

she needed surgery, he was in town on December 19, 2015 for the holidays and he examined her 

shoulder. Appellant advised that he recommended a left shoulder MRI scan as it was possible that 

she may have a rotator cuff tear and could possibly need surgery.

In an October 14, 2016 report, Dr. Evans noted that appellant was seen in his office for 

multiple visits from June 20 to September 13, 2016. He confirmed the history of injury and 

provided findings which included that appellant was tender and had pain when her arm was 
4

elevated above 90 degrees. Dr. Evans found her ligaments were intact. He reviewed the MRI scan 

findings from September 21, 2016 and concluded that appellant had shoulder pain, which was a 

result of the injury at the workplace.

By decision dated October 27, 2016, OWCP denied appellant’s claim. It found that the 

evidence of record was insufficient to establish that the claimed medical condition was causally 

related to the accepted work event(s). 

Following its decision OWCP received copies of prior reports.

On April 28 and May 1, 2017 appellant requested reconsideration. She noted that she was 

providing two letters one from Dr. Evans and one from her son. Appellant explained that

Dr. Evans had been treating her since the injury of June 13, 2016. She indicated that she believed 

that her claim was unfairly denied because both injuries to her shoulder happened at work. 

Appellant denied any prior shoulder problems. She also explained why she never filed for the first 

injury. Appellant noted that, when she injured her left shoulder on June 13, 2016, it was more 

painful, so she filed a claim.

In an undated report, Dr. Randall Roy, an orthopedic sports specialist, and appellant’s son, 

noted that on December 19, 2015 he examined her shoulder at her home due to an injury sustained 

at work earlier that week. He noted that he found weakness in her left shoulder, and recommended 

that she get a left shoulder MRI scan, as he suspected a rotator cuff injury. Dr. Roy explained that,

to his knowledge, appellant had not received treatment for this problem and continued to have 

pain.

In a March 30, 2017 report, Dr. Evans noted that appellant’s left shoulder pain was not 

improving. He repeated the history of injury of June 13, 2016. Dr. Evans opined that this was a 

work injury. He recommended an orthopedic evaluation.

By decision dated July 27, 2017, OWCP denied modification of the October 27, 2016 

decision.

LEGAL PRECEDENT

A claimant seeking benefits under FECA 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.3

To determine if an employee sustained a traumatic injury in the performance of duty, 

OWCP begins with an analysis of whether “fact of injury” has been established. Generally, fact 

of injury consists of two components that must be considered in conjunction with one another. 

The first component is whether the employee actually experienced the employment incident that 

 

3 20 C.F.R. § 10.115(e), (f); see Jacquelyn L. Oliver, 48 ECAB 232, 235-36 (1996).
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allegedly occurred.4 The second component is whether the employment incident caused a personal 

injury.5 An employee may establish that an injury occurred in the performance of duty as alleged, 

but fail to establish that the disability or specific condition for which compensation is being 

claimed is causally related to the injury.6

Causal relationship is a medical question that requires rationalized medical opinion 

evidence to resolve the issue.7 A physician’s opinion on whether there is a causal relationship 

between the diagnosed condition and the implicated employment factor(s) must be based on a 

complete factual and medical background.8 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 factor(s).9 

In any case where a preexisting condition involving the same part of the body is present 

and the issue of causal relationship, therefore, involves aggravation, acceleration, or precipitation, 

the physician must provide a rationalized medical opinion that differentiates between the effects 

of the work-related injury or disease and the preexisting condition.10

ANALYSIS

The Board finds that appellant has not met her burden of proof to establish a left shoulder 

condition causally related to the accepted June 13, 2016 employment incident.

In support of her claim, appellant submitted a series of medical reports from Dr. Evans, an 

internist. Dr. Evans reported that appellant had indicated that she was trying to push a postal 

container through an outer doorway that was blocked on one side by workers. He indicated that 

her subjective complaints included pain in the left shoulder. Dr. Evans initially diagnosed left 

shoulder sprain. He reviewed the MRI scan findings from September 21, 2016 and concluded that 

appellant had shoulder pain, which was a result of the injury at the workplace. Dr. Evans opined 

that he believed that her condition was the result of a work injury. He recommended an orthopedic 

evaluation. The Board finds that the medical records of Dr. Evans are insufficient to establish 

appellant’s claim. While he diagnosed a left shoulder sprain he failed to provide medical reasoning 

as to how and why the accepted employment incident would result in such a condition. The mere 

recitation of patient history does not suffice for purposes of establishing causal relationship 

 

4 Elaine Pendleton, 40 ECAB 1143 (1989).

5

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

6 Shirley A. Temple, 48 ECAB 404, 407 (1997).

7 Robert G. Morris, 48 ECAB 238 (1996). 

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

9

Id.

10 Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3e (January 2013).
6

between a diagnosed condition and the employment incident.11 Without explaining 

physiologically how the accepted employment incident caused or contributed to the diagnosed 

conditions, the physician’s reports are of limited probative value.12 Thus, the reports of Dr. Evans 

are insufficient to establish a left shoulder condition causally related to the accepted June 13, 2016 

employment incident. 

Appellant also submitted a medical report Dr. Allen, a Board-certified internist, who noted 

the history of injury. Dr. Allen noted that she had contusions or hematomas on her left shoulder 

and noted they were work related. A medical opinion should reflect a correct history and offer a 

medically sound explanation by the physician of how the specific employment incident 

physiologically caused or aggravated the diagnosed conditions.13 As Dr. Allen merely noted that 

the condition was work related, without any explanation for his opinion, this report is insufficient 

to establish appellant’s claim.

In an undated report, Dr. Roy, an orthopedic sports specialist, noted that on December 19, 

2015 he had examined her shoulder at her home due to an injury sustained at work earlier that 

week. He noted that he found weakness in her left shoulder, and recommended an MRI scan, as 

he suspected a rotator cuff injury. 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.14 This report is, therefore, insufficient to establish appellant’s claim. 

Appellant also submitted MRI scan reports and numerous reports from physical therapists 

who provided treatment. Diagnostic studies, such as MRI scan reports, are of limited probative 

value as they do not address whether the employment incident caused any of the diagnosed 

conditions.15 As to the physical therapy notes, these documents do not constitute competent 

medical evidence because a physical therapist is not considered a “physician” as defined under 

FECA.16 As such, this evidence is also insufficient to meet appellant’s burden of proof.

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

appellant’s belief of causal relationship.17 Appellant’s honest belief that the June 13, 2016 

 

11 See J.G., Docket No. 17-1382 (issued October 18, 2017).

12 See A.B., Docket No. 16-1163 (issued September 8, 2017).

13 See J.M., Docket No. 17-1002 (issued August 22, 2017).

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

15 See J.S., Docket No. 17-1039 (issued October 6, 2017).

16 See M.M., Docket No. 17-1641 (issued February 15, 2018); K.J., Docket No. 16-1805 (issued February 23, 2018); 

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).

17 John D. Jackson, 55 ECAB 465 (2004); William Nimitz ̧ 30 ECAB 57 (1979).
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employment incident caused her medical conditions, however sincerely held, does not constitute 

the medical evidence necessary to establish causal relationship.18 

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 a left shoulder 

condition causally related to the accepted June 13, 2016 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the July 27, 2017 decision of the Office of Workers’

Compensation Programs is affirmed. 

Issued: December 20, 2018

Washington, DC

Christopher J. Godfrey, 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

 

18 See D.A., Docket No. 18-0783 (issued November 8, 2018); H.H., Docket No. 16-0897 (issued 

September 21, 2016).