United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

C.W., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Portland, OR, Employer 

__________________________________________ 

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Docket No. 16-1320 

Issued: March 23, 2017 

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 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On June 13, 2016 appellant, through counsel, filed a timely appeal from an April 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 of the claim. 

ISSUE 

The issue is whether appellant met her burden of proof to establish a recurrence of her 

medical condition causally related to factors of her federal employment injury. 

 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

FACTUAL HISTORY 

On January 27, 2010 appellant, then a 51-year-old expeditor, filed an occupational 

disease claim (Form CA-2) alleging that her right shoulder condition resulted from repetitive 

pushing, pulling, bending, twisting, and stretching associated with handling and placing mail 

trays. She first became aware of her condition on January 14, 2010. Appellant stopped work on 

January 13, 2010 and returned on February 8, 2010. OWCP accepted the claim for right 

shoulder strain and paid wage-loss compensation and medical benefits. In a July 13, 2010 

decision, it denied appellant’s claim for compensation for the period March 27 through April 23, 

2010 as no contemporaneous evidence addressed a period of disability resulting from her 

accepted condition to cause a change in her work status during the claimed period of disability. 

The record reflects that she was released from medical care for her right shoulder condition on 

May 3, 2010. Appellant continued to experience neck symptoms and intermittent shoulder 

symptoms. She underwent cervical spine surgery on August 30, 2010.3

Appellant, on October 6, 2011, filed a claim for compensation (Form CA-7) for disability 

during the period September 30 to October 7, 2011. She indicated that she returned to work on 

October 10, 2011. 

By decision dated December 19, 2011, OWCP denied that appellant sustained a 

recurrence of disability and compensation for time loss from work for the period September 30, 

2011 onward. It found that there was no evidence of a change in the nature and extent of the 

physical findings related to the work injury and the medical evidence did not explain how her 

condition worsened. OWCP noted that appellant’s medical benefits were not affected by the 

decision. 

On December 27, 2011 appellant, through counsel, requested a telephonic hearing before 

an OWCP hearing representative, which was held March 21, 2012. By decision dated May 11, 

2012, an OWCP hearing representative affirmed the December 19, 2011 decision. 

Appellant retired from the employing establishment on January 31, 2013. 

On March 29, 2013 appellant filed a claim for a schedule award (Form CA-7). By 

decision dated September 20, 2013, OWCP denied the claim for schedule award as the evidence 

of record was insufficient to establish that she sustained permanent impairment due to her 

accepted January 14, 2010 work injury. On September 27, 2013 appellant, through counsel, 

requested a telephonic hearing before an OWCP hearing representative, which was held on 

February 24, 2014. By decision dated March 28, 2014, an OWCP hearing representative 

affirmed the denial of the claim for a schedule award. 

 3

 Under File No. xxxxx692, date of injury March 20, 2010, appellant claimed that her cervical stenosis and 

cervical spine surgery of August 30, 2010 resulted from her employment. In a July 28, 2010 decision, OWCP 

denied her claim for compensation as the medical evidence of record in that claim did not demonstrate that the 

cervical stenosis condition was causally related to work factors. By decision dated December 23, 2010, an OWCP 

hearing representative affirmed that the medical evidence was insufficient to meet appellant’s burden of proof that 

she sustained a cervical spine injury that was causally related to her federal employment. By decision dated 

December 5, 2011, the Board affirmed the denial to amend the claim for cervical stenosis. See Docket No. 11-947 

(issued December 5, 2011). 
3

On March 5, 2014 appellant began treatment with Dr. Paul Puziss, an orthopedic surgeon. 

In a report of the same date, Dr. Puziss noted appellant’s history of her right shoulder condition 

and herniated neck discs. He noted that appellant had improved at least 50 percent in the two 

years postcervical fusion at C4-C7, but the fusions did not help her shoulder. Dr. Puziss noted 

that over the past 3.5 years, appellant has had intermittent trouble elevating her shoulder above 

horizontal. He provided examination findings and noted x-ray findings. A diagnosis of chronic 

right subacromial impingement, right rotator cuff tendinitis/tendinopathy, and possible right 

rotator cuff tear with possible subscapularis tear was provided. Dr. Puziss noted that appellant 

was diagnosed three to four years ago with tendinopathy by magnetic resonance imaging (MRI) 

scan and that she had not had an additional MRI scan since she retired on January 3, 2013. He 

indicated that it was possible she has a rotator cuff tear and ordered a new MRI scan. In a 

March 26, 2014 report, Dr. Puziss noted appellant’s March 19, 2014 MRI scan which showed an 

anterosuperior labral tear and tendinopathy. Diagnoses of chronic right subacromial 

impingement, right rotator cuff tendinitis/tendinopathy, anterosuperior labral tear, and partialthickness articular distal supraspinatus tear, possibly symptomatic were provided. 

In an April 25, 2014 report, Dr. Puziss indicated that the recent MRI scan of March 19, 

2014, which demonstrated a partial articular-side distal supraspinatus tear and tendinopathy, was 

worse than the results of the February 2, 2010 MRI scan. He noted that appellant continued to 

have pain in the right trapezius area even after her cervical fusion. Before appellant retired in 

2013, Dr. Puziss indicated that she was patching mail, requiring constant reaching with the right 

shoulder, which increased her shoulder pain. He noted that her shoulder appeared to be 

stationary in 2013 since an impairment rating was provided. However, it has been demonstrated 

that appellant had pains intrinsically in the right shoulder and provided examination findings. 

Dr. Puziss diagnosed chronic right subacromial impingement; partial thickness articular-side 

right distal supraspinatus tear, likely symptomatic due to work; right rotator cuff tendinopathy 

and tendinitis, likely due to work activities, occupational disease; anterosuperior labral tear, 

somewhat symptomatic, work related; and history of healed C4-C5, C5-C6, and C6-C7 fusions 

August 2010. Dr. Puziss indicated that, since appellant does not have evidence of radiculopathy, 

it did not appear that her pain was emanating from the cervical spine. He opined that the chronic 

trapezius pain was more likely, in retrospect, due to the abnormal right shoulder biomechanics, 

i.e., impingement, causing trapezius substitution to a mild, but persistent degree. Dr. Puziss 

requested that appellant’s right shoulder claim be reopened for physical therapy of the shoulder, 

as her shoulder pain was not coming from her neck. He indicated that appellant was retired and 

was chronically partially disabled with regard to her right shoulder. In a May 9, 2014 report, 

Dr. Puziss requested that OWCP authorize physical therapy. He indicated that appellant’s 

original cervical fusions were due to myelopathy and spinal stenosis and that the surgery did not 

help her shoulder. 

On June 10, 2014 appellant filed a recurrence of disability claim (Form CA-2a) for 

medical treatment commencing March 5, 2014 stemming from her accepted January 14, 2010 

injury. She indicated that she had returned to work in February 2010 with restrictions which 

continued until she retired. The employing establishment noted that appellant had two claims for 

a cervical condition, File Nos. xxxxxx692 and xxxxxx311, which OWCP had denied. 

In a June 27, 2014 letter, OWCP acknowledged appellant’s request for continued medical 

treatment due to her accepted right shoulder strain. It advised that for her to be entitled to 
4

additional medical treatment after being released from care, or not receiving care for a significant 

period of time, she needed to provide evidence that her need for treatment was due to a 

worsening of the accepted medical condition without an intervening cause. OWCP noted that 

appellant was released from medical care for her work-related condition on May 3, 2010, and 

that all of the medical reports in her file from May 2010 regarded a cervical condition. It 

requested that she provide additional factual evidence along with copies of all medical records 

for the work-related right shoulder condition and a comprehensive, narrative medical report from 

her treating physician, which contained an opinion supported by medical rationale as to the 

relationship between her current medical condition and the need for treatment and the original 

injury. Appellant was afforded 30 days to submit the requested evidence. 

In medical treatment notes dated May 22, July 27 and 30, November 21, December 13, 

2012, and February 19, 2013, Dr. Prasanna R. Chandran, a family practitioner, noted appellant’s 

right shoulder/trapezius symptoms, only the July 30, 2012 note diagnoses trapezius strain. 

Dr. Chandran also opined that appellant’s lifting and pushing at work had aggravated her chronic 

pain and took her off work for a week. 

In response to its letter, OWCP received appellant’s July 27, 2014 statement. Appellant 

indicated that medical records since the initial injury to date continue to show decreased motion 

to the right shoulder and tightness and tenderness over the trapezius. She stated that 

unfortunately it was considered radicular from the neck and was forgotten given her neck 

condition. 

In a July 23, 2014 report, Dr. Puziss responded to OWCP’s noted deficiencies of his prior 

medical reports. He indicated that in his March 5, 2014 report, he had reported the history of the 

original injury as an overuse of the shoulder, which was why appellant developed her problems 

in the first place. Dr. Puziss denied that there was a specific injury event. He noted that 

appellant did not have a rotator cuff tear. Dr. Puziss presented examination findings and 

diagnosed: chronic right subacromial impingement; partial-thickness articular side right distal 

supraspinatus tear, likely symptomatic due to work; right rotator cuff tendinopathy and tendinitis, 

likely due to work activities, occupational disease; anterosuperior labral tear, somewhat 

symptomatic, work related; and history of C4-C5, C5-C6, and C6-C7 fusions, August 2010, 

healed. 

In a September 3, 2014 report, Dr. Puziss reiterated that appellant’s shoulder conditions 

were due to overuse at work. He noted that now she is off work (retired), it is not surprising that 

her shoulder is 80 percent better. Dr. Puziss reiterated that appellant needed physical therapy for 

the right shoulder and continued to diagnosis chronic right subacromial impingement; partialthickness articular side right distal supraspinatus tear, likely symptomatic due to work; right 

rotator cuff tendinopathy and tendinitis, likely due to work activities, occupational disease; 

anterosuperior labral tear, somewhat symptomatic, work related; and history of C4-C5, C5-C6, 

and C6-C7 fusions, August 2010, healed. 

By decision dated December 18, 2014, OWCP denied the claimed recurrence of medical 

condition. It found that the evidence of record was insufficient to establish that appellant 

required additional medical treatment due to the accepted work injury. OWCP advised that her 

claim remained closed for medical care. 
5

On December 23, 2014 appellant, through counsel, requested a telephonic hearing, which 

was held before an OWCP hearing representative on July 8, 2015. Appellant testified at the 

hearing. She expressed her concern that her claimed right shoulder problems may have gone 

unaddressed due to her neck problems. Appellant stated that her last 1.5 to 2 months of work 

duties prior to her January 31, 2013 retirement consisted of mail repair. She indicated that she 

wanted medical treatment benefits and to have her claim amended for additional right shoulder 

diagnoses. Appellant stated that Dr. Puziss told her the presence of additional work-related right 

shoulder problems were identified by a March 19, 2014 MRI arthrogram study. No additional 

evidence was received. 

By decision dated September 15, 2015, an OWCP hearing representative affirmed 

OWCP’s December 18, 2014 recurrence denial. He found the medical evidence of record 

insufficient to establish a recurrence or worsening of any accepted right shoulder condition and 

the medical evidence was insufficient to establish that the case should be amended or expanded 

for any additional right shoulder conditions. 

On October 30, 2015 OWCP received counsel’s October 27, 2015 request for 

reconsideration. Additional medical evidence was received. 

A March 19, 2014 MRI arthrogram of the right shoulder contained an impression of 

tendinopathy and partial articular surface tearing of the rotator cuff; superior and anterior glenoid 

labral tear; and capacious inferior axillary recess with evidence for previous injury to the inferior 

glenohumeral ligamentous structures. 

Additional medical reports from Dr. Puziss were also received. In a December 23, 2014 

report, Dr. Puziss indicated that appellant was approaching five years since her original right 

shoulder injury. He noted that, while it was accepted for a “strain,” she was mostly treated for 

her neck condition and cervical radiculopathy. Dr. Puziss indicated that appellant still has right 

shoulder pain and has been retired for more than one year. Appellant could raise her arm 

overhead, but not fully, and pains awakened her and were worsened by pushing, pulling, 

reaching, or any other activity. The last shoulder MRI scan was March 19, 2014. Dr. Puziss 

noted that overall appellant’s shoulder was worsening. He noted that her forearm sometimes 

locked up in a spasm and sometimes she has tightness in the right lateral scapula muscles. 

Dr. Puziss provided examination findings and diagnosed chronic right subacromial impingement; 

partial-thickness articular-side right distal supraspinatus tear, likely symptomatic due to work; 

right rotator cuff tendinopathy and tendinitis, likely due to work activities, occupational disease; 

and anterosuperior labral tear, somewhat symptomatic, work related. 

In a January 20, 2015 report, Dr. Puziss indicated that appellant has had no injuries to the 

right shoulder since the accepted employment injury. He noted that overhead range of motion 

was better and she was not awakened by pain. Dr. Puziss diagnosed: chronic right subacromial 

impingement, currently healed; partial-thickness articular-side right supraspinatus tear, currently 

asymptomatic since impingement is better; right rotator cuff tendinopathy and tendinitis, likely 

due to work activities, i.e., occupational disease; and anterosuperior labral tear, currently 

asymptomatic, also likely work related. He opined that appellant’s claim should be accepted for 

the above conditions. Dr. Puziss indicated that she used her shoulder repetitively since age 19 at 
6

the employing establishment, and that she had been retired for two years and does not plan on 

returning to work. 

In a July 29, 2015 report, Dr. Puziss diagnosed mildly recurrent right subacromial 

impingement; partial-thickness articular-side right supraspinatus rotator cuff tear, mildly 

symptomatic; right rotator cuff tendinopathy and tendinitis due to work activities over the years, 

occupational disease; and anterosuperior labral tear, work related due to overuse, currently 

somewhat symptomatic. He noted that appellant has had a combination of radicular and 

shoulder pain for years. The cervical spine surgery did not help her shoulder pain due to internal 

derangement of the right shoulder, which was evidently missed until his examinations. 

Dr. Puziss indicated that because she awakens at night strongly indicates an internal derangement 

of the shoulder and she has been awakening for years. He also noted that, even though she had 

full range of motion on prior examinations, this does not mean that she does not have an internal 

derangement. Rather, it means that she probably did not have a lot of impingement at the time, 

but she tests regarding her shoulder were limited to general strength tests. Dr. Puziss opined that 

appellant had undiagnosed internal derangement of the right shoulder, now specifically known as 

rotator cuff articular-side partial tear and anterosuperior labral tear. He noted the reason for her 

axillary pains was a labral tear causing nocturnal pain. Dr. Puziss noted that appellant’s shoulder 

condition is separate from her cervical condition and that she has a cumulative trauma disorder 

which resulted from over 34 years of working at the employing establishment. 

By decision dated April 20, 2016, OWCP denied modification of its prior decision. It 

found Dr. Puziss’ reports to be of diminished probative value and thus insufficient for appellant 

to meet her burden of proof to establish the claimed recurrence of a medical condition. 

LEGAL PRECEDENT 

Recurrence of a medical condition means a documented need for further medical 

treatment after release from treatment for the accepted condition or injury when there is no 

accompanying work stoppage. Continuous treatment for the original condition or injury is not 

considered a need for further medical treatment after release from treatment, nor is an 

examination without treatment.4

If a claim for recurrence of medical condition is made more than 90 days after release 

from medical care, a claimant is responsible for submitting a medical report supporting a causal 

relationship between the employee’s current condition and the original injury in order to meet 

her burden.5

The employee has the burden of proof to establish that she sustained a recurrence of a 

medical condition that is causally related to her accepted employment injury. To meet this 

burden, the employee must submit medical evidence from a physician who, on the basis of a 

complete and accurate factual and medical history, supports that the condition is causally related 

 4

 20 C.F.R. § 10.5(y). 

5

 Federal (FECA) Procedure Manual, Part 2 -- Recurrences, Chapter 2.1500.4(b) (June 2013); see also J.M.,

Docket No. 09-2041 (issued May 6, 2010). 
7

and supports her conclusion with sound medical rationale.6

 Where no such rationale is present, 

medical evidence is of diminished probative value.7

 

ANALYSIS 

OWCP accepted appellant’s occupational disease claim for right shoulder strain. On 

June 10, 2014 appellant filed a claim for a recurrence of a medical condition for medical 

treatment of the accepted right shoulder strain. 

The record reflects that appellant was concurrently seeking care for a cervical condition 

and the last documented report concerning appellant’s shoulder was on July 30, 2012, when 

Dr. Chandran diagnosed trapezius strain and opined that appellant’s lifting and pushing at work 

had aggravated her chronic pain. Although the medical record from 2010 to 2014 contains 

references to shoulder symptoms, no diagnoses related to the shoulder were provided. Rather the 

records primarily dealt with appellant’s cervical condition or was considered part of her cervical 

radiculopathy, both nonaccepted conditions. Although appellant was not formally discharged 

from treatment for her work-related shoulder condition, the sufficiently lengthy gap in treatment 

from May 3, 2010 to July 2012 and from July 2012 to March 2014 has the same effect as a 

formal discharge.8

 It is noted that while Dr. Chandran diagnosed trapezius strain in her July 30, 

2012 report and that appellant’s lifting and pushing at work had aggravated her chronic pain, she 

failed to provide a well-rationalized medical opinion regarding the relationship between the 

trapezius strain to the accepted work injury. Medical evidence that does not offer any 

rationalized opinion regarding the cause of an employee’s condition is of limited probative value 

on the issue of causal relationship.9

Appellant’s release from active treatment in 2010, followed by periods of relative 

inactivity from July 2012 until 2014 justify OWCP’s request that she submit a reasoned medical 

opinion establishing that the additional medical treatment was causally related to an objective 

worsening of the accepted medical condition without an intervening cause.10 In short, appellant 

bears the burden of proof to establish a recurrence of medical condition. 

The Board finds that the evidence of record does not establish that appellant’s current 

need for medical care is related to the accepted work injury. Dr. Puziss noted in several reports 

appellant’s need for physical therapy and diagnosed conditions of recurrent right subacromial 

impingement; partial-thickness articular-side right supraspinatus rotator cuff tear; right rotator 

cuff tendinopathy and tendinitis due to work activities over the years, occupational disease; and 

anterosuperior labral tear, work related due to overuse. He provided varying reports on whether 

appellant’s conditions were symptomatic at any given time. In a September 3, 2014 report, 

 6 O.H., Docket No. 15-0778 (issued June 25, 2015). 

7 Michael Stockert, 39 ECAB 1186, 1187-88 (1988); see Ronald C. Hand, 49 ECAB 113 (1957). 

8 See Kent W. Rasmusen, Docket No. 04-1137 (issued August 4, 2004). 

9 Jaja K. Asaramo, 55 ECAB 200 (2004). 

10 See C.T., Docket No. 15-0634 (issued September 9, 2015). 
8

Dr. Puziss reiterated that her shoulder conditions were due to overuse at work. He noted that 

now she was off work (retired), it was not surprising that her shoulder was 80 percent better. 

Dr. Puziss explained that her chronic trapezius pain was more likely, in retrospect, due to the 

abnormal right shoulder biomechanics, i.e., impingement, causing trapezius substitution to a 

mild, but persistent degree. 

In his December 23, 2014 report, Dr. Puziss noted that it was almost five years since her 

original right shoulder injury and, while it was accepted for a “strain,” she was mostly treated for 

her neck and cervical radiculopathy. He indicated that appellant still had right shoulder pain and 

had been retired for more than one year. Appellant could raise her arm overhead, but not fully, 

and pains awakened her and were worsened by pushing, pulling, reaching, or any other activity. 

Dr. Puziss noted that overall appellant’s shoulder was worsening and that her forearm sometimes 

locked up in a spasm and sometimes there was tightness in the right lateral scapula muscles. In a 

January 20, 2015 report, he indicated that appellant had used her shoulder repetitively since age 

19 at the employing establishment, that she was retired, and his diagnosed conditions should be 

accepted. In a July 29, 2015 report, Dr. Puziss noted that appellant had a combination of 

radicular and shoulder pain for years. He indicated that the cervical spine surgery did not help 

her shoulder pain because she had an internal derangement of the right shoulder, which was 

evidently missed over time until he started seeing her. Dr. Puziss indicated that because she 

awakens at night, it strongly indicates an internal derangement of the shoulder and she had been 

awakening for years. He also noted that even though she had full range of motion on prior 

examinations, this did not mean that she does not have an internal derangement. Rather, it just 

means that she probably did not have a lot of impingement at the time. Dr. Puziss noted that she 

never had tests regarding her right shoulder besides general strength tests. He opined that 

appellant had undiagnosed internal derangement of the right shoulder, now specifically known as 

rotator cuff articular-side partial tear and anterosuperior labral tear. Dr. Puziss reasoned that 

appellant’s axillary pains was due to a labral tear and, for the same reason, she had nocturnal 

pain. He concluded that she sustained a cumulative trauma disorder which resulted from over 34 

years of working at the employing establishment. 

The Board finds that the evidence of record lacks adequate rationale to establish a causal 

connection between the alleged recurrence of her medical condition and the accepted 

employment injury. Dr. Puziss fails to provide a well-rationalized opinion with respect to the 

worsening of the subacromial impingement or the partial thickness right distal supraspinatus tear. 

He also noted that appellant did not have specific tests regarding the shoulder. The absence of 

diagnostic studies along with Dr. Puziss’ speculative point of view renders his reports and 

diagnoses of diminished probative value. Appellant had the burden to submit sufficient medical 

evidence to document the need for further medical treatment. She did not submit such evidence 

as required and thus failed to establish a need for continuing medical treatment.11 To the extent 

appellant is alleging that her current condition is consequential to her accepted employment 

injury, she must submit medical evidence which establishes that her condition is a natural 

consequence of the accepted injury.12

 11 See P.Q., Docket No. 14-1905 (issued May 26, 2015); J.F., 58 ECAB 331 (2006); see K.T., Docket No. 15-

1758 (issued May 24, 2016); see also P.Q., id.; J.F., id. 

12 Supra note 6. 
9

On appeal, counsel argues that the decision is contrary to fact and law. However, for the 

reasons set forth above, appellant has failed to establish that her current need for medical care is 

related to the work injury accepted for right shoulder 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 has not met her burden of proof to establish a recurrence 

of her medical condition causally related to factors of her federal employment injury. 

ORDER 

IT IS HEREBY ORDERED THAT the Office of Workers’ Compensation Programs’ 

decision dated April 20, 2016 is affirmed. 

Issued: March 23, 2017 

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