United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

S.M., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Brooklyn, NY, Employer

__________________________________________

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Docket No. 17-1727

Issued: July 9, 2018

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

PATRICIA H. FITZGERALD, Deputy Chief Judge

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On August 7, 2017 appellant filed a timely appeal from a July 13, 2017 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 the claim.2

ISSUE

The issue is whether appellant met his burden of proof to establish a right shoulder injury 

causally related to an accepted May 4, 2017 employment incident.

 

1 5 U.S.C. § 8101 et seq.

2 The record provided to the Board includes evidence received after OWCP issued its July 13, 2017 decision. The 

Board’s jurisdiction is limited to the evidence that was before OWCP at the time of its 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

FACTUAL HISTORY

On May 11, 2017 appellant, then a 36-year-old mail processing clerk, filed a traumatic 

injury claim (Form CA-1) alleging that, on May 4, 2017, he injured his right shoulder while lifting 

a tray of mail. Appellant stopped work the next day and returned to work on June 13, 2017.

Appellant provided a May 5, 2017 note to his supervisor, D.B., in which he requested 

emergency leave to see a doctor for severe shoulder pain. He noted that he could not lift or move 

his right hand and that the pain began when he awoke. Although he took pain medication, 

appellant was still in severe pain and needed to see an emergency doctor.

In a May 5, 2017 emergency department discharge form, Dr. Richard Wong, an emergency 

medicine specialist, diagnosed rotator cuff impingement syndrome of appellant’s right shoulder. 

General information about rotator cuff tendinitis was provided. Dr. Wong restricted appellant 

from heavy lifting until cleared by his primary care physician.

In a May 6, 2017 note, Dr. Eduard Shnaydman, a family physician and osteopath, requested 

that appellant be excused from work due to illness from May 6 to 13, 2017. 

A May 7, 2017 accident report form noted the history of injury and that appellant had 

finished his assignment and finalized his tour on May 4, 2017. It also indicated that he went to his 

own treating physician on May 5, 2017. In a May 8, 2017 statement, acting supervisor, R.M., 

contended that appellant never reported an injury on May 4, 2017.

In May 11 and 18, 2017 duty status reports(Form CA-17) and an attending physician report 

(Form CA-20), Elizabeth Thomas, a physician assistant, diagnosed appellant with right shoulder 

tendinitis. Appellant was held off work and referred to physical therapy.

3

A May 11, 2017 prescription note from Citimedical indicated that appellant was diagnosed 

with right rotator cuff tendinitis. 

In a June 6, 2017 development letter, OWCP informed appellant that when his claim was

first received it appeared to be a minor injury that resulted in minimal or no lost time from work. 

As such, it administratively approved a limited amount of medical expenses without considering 

the merits of the claim. OWCP since reopened appellant’s claim as appellant had not returned to 

work in a full-time capacity. It requested that he provide additional medical evidence which 

contained a physician’s opinion supported by a medical explanation as to how the reported work 

incident caused or aggravated a medical condition. Appellant was afforded 30 days to provide the 

necessary evidence.

OWCP received supplemental statements from appellant dated June 13 and 14, 2017.

In a May 11, 2017 initial report, Dr. Manuel Ceja, an internist, noted the history of 

appellant’s May 4, 2017 employment incident and indicated that he had not returned to work since 

 

3 Below Ms. Thomas’ signature on the form reports is a stamp indicating the name and address of “Manuel A. Ceja, 

MD AME.” However, the form reports were not signed by the physician.
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the incident. He provided an assessment of right shoulder pain and right shoulder impingement 

syndrome. Dr. Ceja indicated that appellant was not fit for duty and was temporarily totally 

disabled. 

On May 18, 2017 Ms. Thomas completed CA-7 and CA-20 form reports wherein she 

opined that appellant’s right shoulder tendinitis was a result of the employment activity of lifting 

a heavy tray. 

In May 18 and June 1, 2017 reports, Dr. Ceja provided an assessment of unspecified sprain 

of right shoulder joint. He continued to opine that appellant was unfit for duty. 

In a June 5, 2017 report, Dr. Ceja reported that the May 25, 2017 magnetic resonance 

imaging (MRI) scan of appellant’s right shoulder revealed rotator cuff tear and suggested an 

additional labral injury with associated bursitis. He continued to provide an assessment of 

unspecified right shoulder joint sprain. Dr. Ceja indicated that appellant was fit for light duty and 

had temporary total disability. A copy of the May 25, 2017 MRI scan was provided.

CA-7 medical forms dated June 1 and 13, 2017 and CA-20 attending physician forms dated 

June 1, 5, and 13, 2017 were also provided. The reports were signed either by Dr. Ceja or a 

physician with an illegible signature. The duty status reports and attending physician reports dated 

June 1 and 5, 2017 indicated that appellant’s diagnosis of right shoulder tendinitis condition was 

causally related to the employment activity of lifting a heavy tray. The June 13, 2017 duty status 

and attending physician reports indicated that the diagnosed right rotator cuff tear was due to the 

reported injury of lifting a heavy tray. On the CA-20 forms, Dr. Ceja noted with a check mark in 

a box marked “yes” that appellant’s condition was caused or aggravated by an employment injury.

By decision dated July 13, 2017, OWCP denied appellant’s claim. It accepted that the 

May 4, 2017 work incident occurred as alleged and that appellant had been diagnosed with right 

shoulder conditions. However, OWCP found that the medical evidence of record was insufficient 

to establish that appellant’s diagnosed conditions were causally related to the accepted

employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA4 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,

5

including that he or she sustained an injury in the performance of duty and that any 

specific condition or disability from work for which compensation is claimed is causally related 

to that employment injury.6

 

4 Supra note 1. 

5

J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968).

6 G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989).
4

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether fact of injury has been established.7 There 

are two components involved in establishing 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.8 Second, the employee must submit evidence, generally 

only in the form of probative medical evidence, to establish that the employment incident caused 

a personal injury.9 An employee may establish that the employment incident occurred as alleged,

but fail to show that his or her disability or condition relates to the employment incident.10

Causal relationship is a medical question that generally requires the submission of 

rationalized medical opinion evidence to resolve the issue.

11

 The opinion of the physician must 

be based on a complete factual and medical background of the employee, 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 employee.12 The weight of the 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.13

ANALYSIS

The Board finds that appellant failed to establish that he sustained a right shoulder injury 

causally related to the accepted May 4, 2017 employment incident. 

Dr. Ceja initially evaluated appellant on May 11, 2017. He noted the history of the May 4, 

2017 employment incident and diagnosed right shoulder pain and right shoulder impingement 

syndrome. In subsequent reports, Dr. Ceja diagnosed unspecified sprain of right shoulder joint. 

While Dr. Ceja accurately reported the history of the May 4, 2017 incident, he did not opine that 

appellant’s right shoulder conditions were causally related to the May 4, 2017 employment

incident. The Board has held that medical evidence that does not offer any opinion regarding the 

cause of an employee’s condition is of limited probative value on the issue of causal relationship.14

While Dr. Ceja submitted Form CA-20 and Form CA-17 reports which opined that 

appellant’s conditions of right shoulder tendinitis and right shoulder rotator cuff tear were due to 

 

7 S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005).

8 Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968).

9 David Apgar, 57 ECAB 137 (2005); John J. Carlone, 41 ECAB 354 (1989).

10 T.H., 59 ECAB 388 (2008); see also Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006).

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

12 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 465 (2005).

13 James Mack, 43 ECAB 321 (1991).

14 C.B., Docket No. 09-2027 (issued May 12, 2010); J.F., Docket No. 09-1061 (issued November 17, 2009); A.D.,

58 ECAB 149 (2006).
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the work incident of lifting a heavy tray, those reports are also insufficient to establish appellant’s 

claim as Dr. Ceja did not provide a rationalized explanation, supported by objective findings, to 

establish whether or how the diagnosed conditions were caused or affected by the May 4, 2017 

work incident. A medical report is of limited probative value on the issue of causal relationship if 

it contains a conclusion regarding causal relationship which is unsupported by medical rationale.15 

On the CA-20 forms he checked a box marked “yes” indicating that appellant’s diagnosed 

conditions were caused or aggravated by his federal employment activity. The Board has held that 

form reports which contain a box checked “yes” in support of causal relationship, without further 

explanation or rationale, are insufficient to establish the claim.

16

In the May 5, 2017 emergency department report, Dr. Wong diagnosed rotator cuff 

impingement syndrome of the right shoulder. However, this report is also insufficient to establish 

appellant’s claim as Dr. Wong did not provide an opinion on the cause of appellant’s right shoulder 

condition.17

The MRI scan report of record is of limited probative value because it is a diagnostic test 

which provides only interpretative data. The Board has held that reports of diagnostic tests are of 

limited probative value as they fail to provide an opinion on the causal relationship between 

appellant’s employment duties and the diagnosed conditions. For this reason, this evidence is 

insufficient to meet appellant’s burden of proof.18

The medical form reports by physician assistant Ms. Thomas also fail to establish 

appellant’s traumatic injury claim. Physician assistants are not considered physicians as defined 

under FECA and their medical opinions regarding diagnosis and causal relationship are of no 

probative value.19 

The work excuse and prescription notes are not probative medical evidence as they do not 

contain rationalized medical opinion that appellant’s diagnosed conditions were causally related 

to his accepted May 4, 2017 employment incident.20

The Board, therefore, finds that appellant has not met his burden of proof to establish an 

injury causally related to the accepted May 4, 2017 employment incident.

 

15 S.E., Docket No. 08-2214 (issued May 6, 2009); T.M., Docket No. 08-0975 (issued February 6, 2009). 

16 See R.S., Docket No. 15-1834 (issued December 23, 2015). 

17 See supra note 14.

18 See A.B., Docket No. 17-0301 (issued May 19, 2017).

19 5 U.S.C. § 8101(2); Roy L. Humphrey, 57 ECAB 238 (2005). Section 8102(2) of FECA provides that the term 

physician includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic 

practitioners within the scope of their practice as defined by State law. See also R.H., Docket No. 16-1802 (issued 

February 1, 2017) (physician assistants are not considered physicians under FECA).

20 See John W. Montoya, 54 ECAB 306 (2003).
6

On appeal appellant reiterates that he injured his right shoulder while lifting a heavy tray 

of mail and was treated for same. The issue of causal relationship is a medical question that must 

be established by probative medical opinion from a physician.21 As explained above, appellant 

has not submitted such probative medical evidence in this case. Thus, the Board finds that he has 

not met his burden of proof. 

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 his burden of proof to establish a right shoulder 

injury causally related to the accepted May 4, 2017 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the July 13, 2017 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: July 9, 2018

Washington, DC

Patricia H. Fitzgerald, Deputy 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

 

21 W.W., Docket No. 09-1619 (issued June 2, 2010); David Apgar, 57 ECAB 137 (2005).