United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

S.G., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Brooklyn, NY, Employer

__________________________________________

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Docket No. 18-1373

Issued: February 12, 2019

Appearances: Case Submitted on the Record

Raymond Bermudez, 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 July 5, 2018 appellant, through his representative, filed a timely appeal from an 

April 25, 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.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 Board notes that appellant submitted additional evidence on appeal. However, the Board’s Rules of 

Procedure provides: “The Board’s review of a case is limited to the evidence in the case record that was before 

OWCP at the time of its final decision. Evidence not before OWCP will not be considered by the Board for the first 

time on appeal.” 20 C.F.R. § 501.2(c)(1). Thus, the Board is precluded from reviewing this additional evidence for 

the first time on appeal. Id.
2

ISSUE

The issue is whether appellant has met his burden of proof to establish that his right arm 

and left leg conditions were causally related to the accepted August 29, 2017 employment incident. 

FACTUAL HISTORY

On August 29, 2017 appellant, then a 52-year-old mail handler, filed a traumatic injury 

claim (Form CA-1) alleging that, on that same date, while in the performance of duty, he was 

trying to turn a sidewinder to move pallets when he fell off the sidewinder. He reported that the 

fall caused him to twist his left leg and bruise his right arm. Appellant notified his supervisor, 

stopped work, and sought emergency medical treatment on the date of the incident.

On the alleged date of injury the employing establishment issued appellant a properly 

completed authorization for examination and/or treatment (Form CA-16), which indicated that he

was authorized to seek medical treatment at Brookdale Medical Center. An August 29, 2017 

Brookdale Emergency Department note documents appellant’s treatment for contusion of the 

lower leg. Appellant was released to return to work on September 2, 2017.

In a September 6, 2017 duty status report (Form CA-17), a physician medical provider

indicated that appellant was disabled and unable to resume work as a result of a left calf strain and 

contusion.4

By development letter dated September 20, 2017, OWCP notified appellant that his claim 

was initially administratively handled to allow medical payments, as it appeared to involve a minor 

injury resulting in minimal or no lost time from work. However, the merits of his claim had not 

been formally considered and his claim had been reopened for consideration of the merits because 

he had not returned to work in a full-time capacity. OWCP informed appellant that the evidence 

of record was insufficient to establish his traumatic injury claim. It advised appellant of the 

medical and factual evidence needed and afforded 30 days to submit the additional evidence.

In a September 6, 2017 medical report, Dr. Todd Soifer, a Board-certified orthopedic 

surgeon, reported that appellant injured his left calf region while at work on August 29, 2017. He

provided findings on physical examination and noted that an x-ray of the left leg revealed no 

fracture. Dr. Soifer diagnosed left calf contusion and left calf strain/derangement. He further 

recommended a walker and provided work restrictions.

In a September 20, 2017 addendum report, Dr. Soifer reported that appellant’s Doppler 

lower extremity study of the left leg revealed “soleal DVT [deep vein thrombosis].” Appellant 

was referred to a vascular specialist for treatment.

In a September 28, 2017 medical report, Dr. Soifer reported that appellant’s left calf 

condition had improved. Appellant also reported a right forearm injury from the employment 

incident which had yet to resolve. Dr. Soifer provided findings on physical examination and 

diagnosed right forearm strain. He further recommended a Doppler study of the upper extremities. 

 

4 The physician’s signature is illegible. 
3

Dr. Soifer provided Form CA-17s dated September 25 and 28, 2017, which restricted appellant 

from returning to work due to a torn calf muscle.

By decision dated October 25, 2017, OWCP denied appellant’s claim, finding that the 

evidence of record was insufficient to establish that his diagnosed medical conditions were 

causally related to the accepted August 29, 2017 employment incident.

On November 16, 2017 appellant requested review of the written record by an OWCP 

hearing representative.

In a September 22, 2017 diagnostic report, Dr. Gary Gwertzman, a Board-certified 

vascular surgeon, reported that a lower limb venous duplex scan revealed left acute DVT of the 

mid soleal vein. In a September 28, 2018 upper limb venous duplex scan, he reported that the right 

arm revealed no evidence of upper extremity superficial phlebitis or DVT.

In an October 16, 2017 medical report, Dr. Scott Weiss, a Board-certified orthopedic 

surgeon, reported that appellant presented for evaluation of left leg pain after he fell at work on 

August 29, 2017. Appellant was using crutches and reported difficulty walking due to pain in the 

left calf. He noted that the left calf was initially black and blue and swollen, but had improved 

significantly since the injury. Dr. Weiss reported that appellant was unable to get a magnetic 

resonance imaging (MRI) scan because of his cochlear implants. He noted that appellant also 

scratched his right arm during his fall, which had resolved, other than some residual numbness on 

the right fifth finger. Dr. Weiss diagnosed pain in left knee, paresthesia of skin, strain of 

muscle/tendon of left lower leg, and sprain of medial collateral ligament of left knee. He also 

noted a diagnosis of left calf strain/partial tear of the medial gastrocnemius muscle. With respect 

to appellant’s right arm, Dr. Weiss diagnosed right fifth finger paresthesias, which he opined could 

be a mild case of cubital tunnel syndrome.

In medical notes dated October 19 and November 16, 2017, Dr. Soifer noted appellant’s 

treatment and progress for his left lower extremity conditions.

In a November 7, 2017 report, Dr. Soifer related that he first evaluated appellant on 

September 6, 2017 as a result of an August 29, 2017 employment injury when he hurt his left calf 

region. He reported that physical examination revealed moderate medial and lateral gastroc 

tenderness, as well as local swelling and medial and lateral ecchymosis. The diagnosis at that time 

was left calf strain derangement. While his condition had somewhat improved, appellant’s 

September 20, 2017 evaluation revealed continued moderate medial gastroc tenderness. He was 

referred for a Doppler study of his leg which revealed a clot, causing him to seek treatment with

Dr. Gwertzman for soleal DVT. Dr. Soifer reported that appellant’s left calf continued to improve 

with just a trace of discomfort on the medial side and slight discomfort on the lateral side. He

diagnosed medial calf strain and subsequent DVT. Dr. Soifer opined that, based on the history, 

there was a close relationship between the condition described and the employment incident. He

concluded that appellant had been disabled from his employment since the time of his last visit, 

although his condition was improving.

In a March 20, 2018 narrative statement, appellant described the circumstances 

surrounding the August 29, 2017 employment incident. 
4

By decision dated April 25, 2018, OWCP’s hearing representative affirmed the 

October 25, 2017 decision, finding that the evidence of record was insufficient to establish that the 

diagnosed medical conditions were causally related to the accepted August 29, 2017 employment 

incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA5 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.6 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.7

In order to determine whether an employee actually sustained an 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, which must be considered in conjunction with one 

another. The first component to be established is that the employee actually experienced the 

employment incident which is alleged to have occurred.8 The second component is whether the 

employment incident caused a personal injury and generally can be established only by medical 

evidence. 

Causal relationship is a medical issue, and the medical evidence required to establish causal 

relationship is rationalized medical evidence.9 The opinion of the physician must be based on a 

complete factual and medical background of the claimant, 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. 

This medical opinion must include an accurate history of the employee’s employment injury and 

must explain how the condition is related to the injury. The weight of medical evidence is 

determined by its reliability, its probative value, its convincing quality, the care of analysis 

manifested, and the medical rationale expressed in support of the physician’s opinion.10

 

5 Supra note 2.

6 Gary J. Watling, 52 ECAB 278 (2001).

7 Michael E. Smith, 50 ECAB 313 (1999).

8 Elaine Pendleton, 40 ECAB 1143 (1989).

9

J.P., Docket No. 18-1165 (issued January 15, 2019). 

10 James Mack, 43 ECAB 321 (1991).
5

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish that his left calf 

and right arm conditions were causally related to the accepted August 29, 2017 employment 

incident.11 

The record reflects that appellant sought immediate emergency medical treatment 

following the August 29, 2017 employment incident. While the Brookdale Hospital Emergency 

Department note documented treatment for a left lower leg contusion, this report lacked a history 

of injury and opinion regarding the cause of the diagnosed condition. As this medical report lacked 

both a proper history and a rationalized opinion regarding causal relationship, it is of limited 

probative value.12

Appellant also submitted medical and form reports dated September 6 to November 7, 

2017 from Dr. Soifer, his attending physician. The Board finds that the opinion of Dr. Soifer is 

not well rationalized. While he provided a diagnosis of left medial calf strain and subsequent 

DVT, Dr. Soifer failed to provide a fully rationalized opinion that appellant’s left lower extremity 

conditions were causally related to the accepted August 29, 2017 employment incident. He opined 

that, based on appellant’s history, there was a close relationship between the condition described 

and the history of injury. The Board notes that Dr. Soifer did not definitively relate appellant’s 

diagnosed medical conditions to the accepted August 29, 2017 employment incident. Dr. Soifer’s

opinion on causation is highly speculative and couched in equivocal terms. To be of probative 

value, a physician’s opinion on causal relationship should be one of reasonable medical certainty.13 

Moreover, Dr. Soifer failed to provide a detailed history of the employment incident, only 

generally noting that appellant injured his left calf region at work on August 29, 2017. Without 

an understanding of the employment incident, any opinion on causal relationship is of limited 

probative value as the physician is unable to describe how the incident caused appellant’s injury.14 

Dr. Soifer’s reports lack the specificity and detail needed to establish appellant’s claim.15 

Dr. Soifer further failed to establish a work-related right arm injury. While he provided a 

firm medical diagnosis of right forearm sprain, he did not provide an opinion on the cause of this 

condition. As such, Dr. Soifer’s reports are of no probative value,16 and are thus insufficient to 

meet appellant’s burden of proof.17

 

11 See Robert Broome, 55 ECAB 339 (2004).

12 See Z.D., Docket No. 16-0934 (issued November 8, 2016). 

13 See Beverly R. Jones, 55 ECAB 411 (2004).

14 See L.M., Docket No. 14-0973 (issued August 25, 2014); R.G., Docket No. 14-0113 (issued April 25, 2014); 

K.M., Docket No. 13-1459 (issued December 5, 2013); A.J., Docket No. 12-0548 (issued November 16, 2012).

15 P.O., Docket No. 14-1675 (issued December 3, 2015); S.R., Docket No. 12-1098 (issued September 19, 2012).

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

17 See Michael R. Shaffer, 55 ECAB 339 (2004).
6

The Board finds that Dr. Weiss’ October 16, 2017 report is also insufficient to establish 

appellant’s traumatic injury claim. While Dr. Weiss provided a diagnosis of strain of 

muscle/tendon of left lower leg and sprain of medial collateral ligament of left knee, he failed to 

provide any opinion regarding the cause of appellant’s conditions. 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.18 

The remaining medical evidence of record is also insufficient to establish appellant’s claim. 

Dr. Gwertzman’s diagnostic reports of record dated September 22 and 28, 2017 simply interpret 

imaging studies. The Board has held that reports of diagnostic tests lack probative value as they 

do not provide an opinion on causal relationship between appellant’s employment and a diagnosed 

condition.19 The Board finds, therefore, that this evidence is insufficient to establish appellant’s 

claim.

The fact that a condition manifests itself during a period of employment is insufficient to 

establish causal relationship.20 Temporal relationship alone will not suffice. Entitlement to FECA 

benefits may not be based on surmise, conjecture, speculation, or on the employee’s own belief of 

a causal relationship.21 In the instant case, the record lacks rationalized medical evidence 

establishing causal relationship between the August 29, 2017 employment incident and his 

diagnosed conditions.

22

 Thus, appellant has failed to meet his burden of proof.23

Appellant may submit additional evidence, together with a written request for

reconsideration, to OWCP within one year of the Board’s 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 his burden of proof to establish that his right 

arm and left leg conditions were causally related to the accepted August 29, 2017 employment 

incident. 

 

18 See supra note 16.

19 See P.Y., Docket No. 18-1136 (issued January 7, 2019). 

20 Daniel O. Vasquez, 57 ECAB 559 (2006).

21 D.D., 57 ECAB 734 (2006).

22 See J.S., Docket No. 17-0507 (issued August 11, 2017).

23 The record contains a Form CA-16 signed by the employing establishment official on August 29, 2017 for 

treatment pertaining to the employment injury. When the employing establishment properly executes a Form CA-16 

which authorizes medical treatment as a result of an employee’s claim for an employment-related injury, the Form 

CA-16 creates a contractual obligation, which does not involve the employee directly, to pay for the cost of the 

examination or treatment regardless of the action taken on the claim. The period for which treatment is authorized by 

a Form CA-16 is limited to 60 days from the date of issuance, unless terminated earlier by OWCP. See 20 C.F.R. 

§ 10.300(c); Tracy P. Spillane, 54 ECAB 608 (2003). 
7

ORDER

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

decision dated April 25, 2018 is affirmed.

Issued: February 12, 2019

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