United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

T.J., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Denver, CO, Employer

__________________________________________

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Docket No. 18-1500

Issued: May 1, 2019

Appearances: Case Submitted on the Record

Appellant, pro se

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 August 1, 2018 appellant filed a timely appeal from a June 7, 2018 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 this case.2

ISSUE

The issue is whether appellant has met her burden of proof to establish a medical condition 

causally related to the accepted November 26, 2017 employment incident. 

 

1 5 U.S.C. § 8101 et seq.

2 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

FACTUAL HISTORY

On December 4, 2017 appellant, then a 64-year-old laborer/custodian, filed a traumatic 

injury claim (Form CA-1) alleging that, on November 26, 2017, she sustained a chest wall muscle 

spasm when pulling a shampooer through a confined space while in the performance of duty. She

stopped work on November 26, 2017 and returned on December 4, 2017. On the reverse side of 

the claim form, appellant’s supervisor contended that the injury was caused by willful misconduct.

In a November 26, 2017 narrative statement, appellant’s supervisor, D.W., explained that,

on November 26, 2017, appellant complained of foot pain and asserted that she was unable to push 

the scrubber to the work site as required. He explained that he demonstrated the proper way to use 

the machine and how to push the scrubber to the job site.

In a November 30, 2017 duty status report (Form CA-17), Dr. Natalie Ronshaugen, a 

family medicine specialist, noted that appellant was pulling a shampoo machine and pulled a 

muscle. She diagnosed chest wall muscle spasm. Dr. Ronshaugen indicated that appellant could 

return to light-duty work on December 4, 2017.

In a development letter dated December 29, 2017, OWCP informed appellant that 

additional factual and medical information was required to establish the claim. It advised her of 

the type of factual and medical evidence needed and provided a questionnaire for her completion. 

In a separate development letter, also dated December 29, 2017, OWCP requested that the 

employing establishment provide further clarification of the facts of appellant’s claim. It afforded 

both parties 30 days to respond.

Thereafter, OWCP received November 26, 2017 hospital records and treatment notes. 

Dr. John Lemery, Board-certified in emergency medicine, noted that appellant was “lifting a heavy 

shampoo device at work today at 1530.” He diagnosed bilateral low back pain without sciatica of 

unspecified chronicity. Dr. Lemery also noted that appellant’s pain radiated to her back, but not 

her left arm. He also noted that she had similar symptoms in 2015 with a diagnosis of a pulled 

muscle. 

In a November 26, 2017 emergency department treatment note, Dr. Alexander Quinones, 

an emergency medicine specialist, determined that appellant had bilateral low back pain without 

sciatica of unspecified chronicity.

In a January 25, 2018 statement, D.W. provided photographs of the carpet cleaning 

machine, which had wheels. He explained that appellant’s duties included moving the carpet 

cleaner and cleaning on both November 12 and 26, 2017. D.W. explained that, despite being 

instructed on how to push the carpet cleaner, appellant pulled the carpet cleaner.

By decision dated February 1, 2018, OWCP denied appellant’s claim. It found the 

evidence of record was insufficient to establish that the event occurred as described. OWCP 

explained that appellant claimed that she was “pulling a shampooer at work thru a confined space.” 

It explained that despite being provided guidance on how to push the shampoo machine between 

job sites, appellant pulled the shampooer instead of using the guidance to push the shampooer, 
3

which cast doubt on her claim. OWCP also found that she had not responded to the December 29, 

2017 request for additional information.

3

In a narrative report dated November 30, 2017, Dr. Ronshaugen indicated that appellant 

was seen for “severe chest wall muscle spasm from pulling a shampooer at work.” She 

recommended physical therapy and light duty until appellant’s pain resolved, at which time she 

could resume full[-]duty activity at work.”

In a February 1, 2018 statement, appellant explained that she had to pull the carpet cleaner 

through the doors because they were not automatic doors. She explained that she could not push 

the machine without assistance.

In a February 1, 2018 report, Dr. Susan Piggot, a family medicine specialist, noted

appellant was seen on November 30, 2017 for an injury. She diagnosed “chest wall muscle spasm”

and recommended physical therapy.

OWCP received a February 22, 2018 duty status report (Form CA-17) with an illegible 

signature. The diagnosis was chest pain and muscle spasm. 

On March 7, 2018 OWCP’s Branch of Hearings and Review received a request for a review 

of the written record before an OWCP hearing representative. 

By decision dated June 7, 2018, OWCP’s hearing representative affirmed the February 1, 

2018 decision, as modified. He accepted that the claimed incident occurred as alleged, but found 

that appellant had not established a medical condition causally related to the accepted 

November 26, 2017 employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA 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 timely filed within the applicable 

time limitation period,4that an injury was sustained in the performance of duty as alleged, and that 

any disability or medical condition for which compensation is claimed is causally related to the 

 

3 On January 17, 2018 appellant sought an appeal from a purported decision of OWCP dated December 29, 2017. 

The Board assigned Docket No. 18-0521. However, the Board found that there was no final adverse OWCP decision 

at the time appellant filed her appeal. The Board determined that the purported December 29, 2017 decision was, in 

actuality, an initial development letter from OWCP advising appellant of the deficiencies in her claim and requesting 

specific factual and medical evidence. The Board concluded that the appeal must be dismissed. Order Dismissing 

Appeal, Docket No. 18-0521 (issued February 16, 2018).

4 S.B., Docket No. 17-1779 (issued February 7, 2018); J.P., 59 ECAB 178 (2007); Joe D. Cameron, 41 ECAB 

153 (1989).
4

employment injury.5 These are the essential elements of each and every compensation claim, 

regardless of whether the claim is predicated upon a traumatic injury or an occupational disease.6

To determine if an employee has 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 

allegedly occurred.7 The second component is whether the employment incident caused a personal 

injury.8 

Rationalized medical opinion evidence is required to establish causal relationship. The 

opinion of the physician must be based on a complete factual and medical background, must be 

one of reasonable medical certainty, and must be supported by medical rationale explaining the 

nature of the relationship between the diagnosed medical condition and the specific employment 

incident.9

ANALYSIS

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

condition causally related to the accepted November 26, 2017 employment incident. 

OWCP received November 26, 2017 hospital records and treatment notes from

Dr. Lemery. Dr. Lemery described the November 26, 2017 employment incident, noted 

appellant’s history of similar symptoms in 2015, when she was diagnosed with a pulled muscle. 

He indicated that appellant’s current diagnosis was bilateral low back pain without sciatica of 

unspecified chronicity. The Board notes that pain is a symptom, not a compensable medical 

diagnosis.10 Dr. Lemery did not diagnose an actual medical condition causing the pain.11 His 

report is therefore of limited probative value.

Appellant was also treated on November 26, 2017 by Dr. Quinones. His treatment notes 

similarly are of limited probative value because he also diagnosed bilateral low back pain without 

 

5

J.M., Docket No. 17-0284 (issued February 7, 2018); R.C., 59 ECAB 427 (2008); James E. Chadden, Sr., 40 

ECAB 312 (1988).

6 K.M., Docket No. 15-1660 (issued September 16, 2016); L.M., Docket No. 13-1402 (issued February 7, 2014); 

Delores C. Ellyett, 41 ECAB 992 (1990).

7 Elaine Pendleton, 40 ECAB 1143 (1989).

8 M.H., Docket No. 18-1737 (issued March 13, 2019); John J. Carlone, 41 ECAB 354 (1989). 

9 S.S., Docket No. 18-1488 (issued March 11, 2019). 

10 C.M., Docket No. 18-0146 (issued August 16, 2018).

11 See D.K., Docket No. 17-1186 (issued June 11, 2018). 
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sciatica of unspecified chronicity. As previously noted, pain is a symptom, not a compensable 

medical diagnosis.12

Dr. Ronshaugen saw appellant on November 30, 2017 for “severe chest wall muscle spasm 

from pulling a shampooer at work.” In a February 1, 2018 report, Dr. Piggot also diagnosed “chest 

wall muscle spasm.” A muscle spasm has also been found to be a symptom, not a diagnosis.13 

The Board has held that a medical report is of no probative value if it does not provide a firm 

diagnosis of a particular medical condition, or offer a specific opinion as to whether the accepted 

employment incident caused or aggravated the claimed condition.

14

 As neither Dr. Ronshaugen

nor Dr. Piggot diagnosed an actual medical condition causing appellant’s symptoms, their reports 

lack probative value and are insufficient to establish the claim.

15

OWCP received a February 22, 2018 duty status report (Form CA-17) with an illegible 

signature. A report that is unsigned or bears an illegible signature lacks proper identification and 

cannot be considered probative medical evidence.16 

The Board finds that appellant has not submitted rationalized, probative medical evidence 

sufficient to establish a diagnosed medical condition causally related to her employment incident 

of November 26, 2017.

17

 Appellant, therefore, has not met her burden of proof. 

On appeal appellant questions her supervisor’s controversion of her claim, contending that 

he did not witness the injury. The Board notes, however, that the November 26, 2017 employment 

incident has already been accepted as having occurred as alleged. For the reasons set forth above, 

the claim is denied because the medical evidence of record is insufficient to establish a diagnosed 

medical condition causally related to the accepted November 26, 2017 employment incident. 

Therefore, appellant has not met her burden of proof to establish an employment-related injury. 

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 medical 

condition causally related to the accepted November 26, 2017 employment incident. 

 

12 Id.

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

14 See M.J., Docket No. 18-1114 (issued February 5, 2019). 

15 See supra note 11. 

16 Thomas L. Agee, 56 ECAB 465 (2005); Richard F. Williams, 55 ECAB 343 (2004). 

17 See D.S., Docket No. 18-0061 (issued May 29, 2018).
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ORDER

IT IS HEREBY ORDERED THAT the June 7, 2018 decision of the Office of Workers’

Compensation Programs is affirmed. 

Issued: May 1, 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