United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

Y.P., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS HEALTH ADMINISTRATION, 

Buffalo, NY, Employer

__________________________________________

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Docket No. 17-0859

Issued: December 4, 2018

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 March 9, 2017 appellant filed a timely appeal from a December 13, 2016 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 recurrence of 

disability on October 7, 2015, causally related to her accepted March 18, 2014 employment injury.

 

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 evidence for the first time on appeal. Id. 
2

FACTUAL HISTORY

On April 19, 2014 appellant, then a 47-year-old practical nurse, filed a traumatic injury 

claim (Form CA-1) alleging that she injured her left knee on March 18, 2014 as a result of 

attempting to sit in a chair while in the performance of duty. She stated that the chair slipped from 

behind her, which caused her to fall to the floor, injuring her left knee. OWCP initially denied the 

claim by decision dated August 8, 2014, because it found that the medical evidence was 

insufficient to establish causal relationship. Subsequently, by decision dated February 19, 2015, 

an OWCP hearing representative reversed the decision and returned the case for acceptance of left 

knee medial meniscus tear. By decision dated March 6, 2015, OWCP accepted appellant’s claim 

for left knee medial meniscus tear. It also authorized two left knee surgeries which appellant 

underwent on September 29, 2014 and January 20, 2015.

In a June 9, 2015 report, Dr. Michael A. Rauh, a Board-certified orthopedic surgeon, 

released appellant to light-duty work with the following restrictions: walking and standing up to 

eight (8) hours per day, no bending/stooping, pushing, pulling, and lifting no more than 10 pounds, 

and no squatting, kneeling, or climbing with occasional stair use.

On June 10, 2015 appellant accepted a light-duty job offer from the employing 

establishment as a modified licensed practical nurse. The position required scheduled six 12-hour 

shifts and one 8-hour shift per pay period. The physical requirements included occasional stair 

climbing, standing, or walking limited to 12 hours, no bending, stooping, squatting, or kneeling,

lifting limited to less than 10 pounds, pushing or pulling less than 10 pounds, and sedentary work 

only.

Subsequently, on September 8, 2015 appellant accepted a job as a modified procedure 

scheduler. The tour of duty was Monday through Friday (two shifts) from 7:00 a.m. to 3:30 p.m. 

and 8:00 a.m. to 4:30 p.m. The physical requirements included standing or walking limited to 12 

hours, lifting limited to less than 10 pounds, and pushing or pulling less than 10 pounds.

An x-ray dated October 7, 2015 demonstrated an L4-5 anterolisthesis and decreased disc 

height at L5-S1.

In an October 7, 2015 report, Dr. Lindsey Clark, an orthopedic surgeon, diagnosed other 

intervertebral disc degeneration, lumbar region, and noted that appellant presented with low back 

pain and bilateral leg pain. He indicated that appellant had a work-related injury to her left knee 

on March 18, 2014, which had caused her to compensate on the right side exacerbating her low 

back pain. Appellant reported 75 percent low back pain and 25 percent leg pain.

On October 21, 2015 Dr. Rauh diagnosed status post left knee anterior cruciate ligament

(ACL) reconstruction with continued left knee pain in the setting of degenerative changes. He 

opined that appellant would benefit from receiving viscosupplementation injections to help 

alleviate her symptoms and possibly allow for improved function and return to daily activities, as 

well as occupational activities.

In two reports dated October 23, 2015, Dr. Clark diagnosed cervicalgia and took appellant 

off of work until further notice.
3

On October 29, 2015 appellant filed a claim for wage-loss compensation (Form CA-7) for 

the period October 19 to 21, 2015.

In a November 2, 2015 letter, OWCP advised appellant that it appeared that she was 

claiming a recurrence of disability and found that it was unclear why she stopped work on 

October 19, 2015. It requested additional medical evidence in support of her claim.

In a November 13, 2015 duty status report (Form CA-17), Dr. Clark diagnosed 

intervertebral disc degeneration and provided work restrictions.

On November 20, 2015 appellant filed a notice of recurrence (Form CA-2a). She stated 

that, when returning back to work, she continued to have left knee pain and burning/popping back

pain which worsened on October 21, 2015. Appellant indicated that she compensated her weight 

to the right side of her body and not being able to put full pressure on her left leg caused her back 

and hip issues. 

In a November 4, 2015 report, Dr. Sridhar Rachala, a Board-certified orthopedic surgeon, 

diagnosed left knee pain, status post ACL reconstruction, mild left knee arthritis, and morbid 

obesity. He checked a box marked “yes” indicating his support for causal relationship, noting that 

the injury occurred while appellant was on duty.

On December 4, 2015 Meghan McNichol, a physician assistant, diagnosed other 

intervertebral disc degeneration, lumbar region, and checked a box marked “yes” indicating her

support for causal relationship, noting that the injury occurred while appellant was on duty.

In a December 11, 2015 letter, OWCP advised appellant of the deficiencies of her 

recurrence claim. It requested additional evidence in support of the claim and afforded appellant 

30 days to respond to its inquiries.

In response, appellant submitted a narrative statement dated December 15, 2015, indicating 

that she returned to work on June 6, 2015.

An October 23, 2015 x-ray of the cervical spine was normal and showed no evidence of 

fracture, subluxation, or degenerative change.

On December 16, 2015 Dr. Rauh diagnosed pain in the left knee and unilateral primary 

osteoarthritis of the left knee. He noted that appellant continued treatment with his spine specialist 

colleague for her lower back and right hip conditions.

In a December 21, 2015 report, Dr. Clark noted that appellant sustained a work injury on 

March 18, 2014 to her left knee and since that injury she had difficulty putting full weight on her 

left lower extremity. Appellant was compensating her weight to her right side, which Dr. Clark 

opined had caused a consequential injury to her lumbar spine. Dr. Clark noted that appellant was 

diagnosed with intervertebral disc degeneration of the lumbar spine and on October 23, 2015 she 

reported worsening of her low back and lateral hip pain. She reported that appellant had been 

working light duty, but was no longer able to tolerate even those duties. Dr. Clark took appellant 

off of work as she was not able to sit, stand, or walk for any prolonged period and advised that she 

was unable to lift, bend, or twist.
4

By decision dated February 10, 2016, OWCP denied appellant’s recurrence claim, finding 

that the medical evidence of record was insufficient to establish a recurrence of her medical 

condition causally related to her March 18, 2014 employment injury. It found that the evidence of 

record was insufficient to establish a return or increase of disability due to a consequential injury 

or condition stemming from appellant’s accepted left knee condition.

Appellant submitted physical therapy reports dated February 15 and 17, 2015 and a 

March 1, 2016 report from a physician assistant in support of her claim.

In a February 12, 2016 report, Dr. Clark continued to diagnose other intervertebral disc 

degeneration, lumbar region, and opined that appellant’s condition was causally related to her 

accepted employment injury.

On March 7, 2016 appellant requested reconsideration and submitted a narrative statement 

dated February 24, 2016.

In a December 22, 2015 report, Dr. Rauh asserted that appellant experienced low back 

pain, which was felt to be causally related to her knee secondary to favoring the left knee 

postoperatively. Appellant continued to have knee pain and subsequently began to experience low 

back discomfort and was referred to Dr. Clark for evaluation and consultation. She did not have 

any complaints of low back pain prior to her left knee surgery and Dr. Rauh concluded that her 

low back condition was causally related to her work-related injury.

An x-ray dated March 1, 2016 revealed moderate degenerative changes of the medial 

compartment of the knees bilaterally.

In a March 10, 2016 report, Dr. Elizabeth D. Ditonto, a Board-certified anesthesiologist 

and pain medicine specialist, diagnosed possible lumbar radiculopathy with known disc disease 

and foraminal stenosis, possible facet syndrome, and ongoing knee pain status post trauma and 

surgery. She asserted that appellant’s accepted left knee injury and surgery affected her gait and 

made her low back pain on the right worse.

On April 5, 2016 Dr. Rauh reported that appellant had a recent fall at work on April 5, 

2016 and diagnosed ACL sprain of the left knee.

In a March 21, 2016 report, Ms. McNichol released appellant to work without restrictions 

on April 4, 2016 and indicated that she would be “doing light duty for her knee.”

By decision dated May 19, 2016, OWCP denied modification of its prior decision.

In response, appellant submitted a physical therapy report dated June 10, 2016 and a July 5, 

2016 narrative statement indicating that she was presently on light duty working four hours per 

day.

On June 20, 2016 Dr. Ditonto administered a lumbar epidural steroid injection with 

epiduragram.

On July 26, 2016 appellant requested reconsideration and argued that she could not 

perform her job duties because of her consequential injuries to her back that came from her knee.
5

In an April 22, 2016 report, Dr. Rauh diagnosed left knee exacerbation of preexisting 

arthritis, no clear evidence of interval ACL tear, possible new posterior horn lateral meniscus tear, 

and medial compartment arthritis due to a new history of injury to her left knee.

Appellant further submitted a physical therapy report dated May 20, 2016.

By decision dated November 21, 2016, OWCP denied modification of its prior decision.

On November 28, 2016 appellant requested reconsideration and submitted a November 2, 

2016 report from Dr. Rauh who continued to diagnose left knee status post ACL reconstruction 

with new onset pain and locking.

By decision dated December 13, 2016, OWCP denied modification of its prior decision,

finding that appellant has not met her burden of proof to establish a recurrence of disability due to 

her accepted work-related injury on March 18, 2014.

LEGAL PRECEDENT

A recurrence of disability means an inability to work after an employee has returned to 

work, caused by a spontaneous change in a medical condition which resulted from a previous 

injury or illness without an intervening injury or new exposure to the work environment that caused 

the illness.3 Recurrence of disability also means an inability to work that takes place when a lightduty assignment made specifically to accommodate an employee’s physical limitations due to his 

work-related injury or illness is withdrawn or when the physical requirements of such an 

assignment are altered so that they exceed his established physical limitations.4 Generally, a 

withdrawal of a light-duty assignment would constitute a recurrence of disability where the 

evidence established continuing injury-related disability for regular duty.5 A recurrence of 

disability does not apply when a light-duty assignment is withdrawn for reasons of misconduct, 

nonperformance of job duties or other downsizing, or where a loss of wage-earning capacity 

determination is in place.6

Absent a change or withdrawal of a light-duty assignment, a recurrence of disability 

following a return to light duty may be established by showing a change in the nature and extent 

of the injury-related condition such that the employee could no longer perform the light-duty 

assignment.7

Where an employee claims a recurrence of disability due to an accepted employmentrelated injury, he or she has the burden of proof to establish that the recurrence is causally related 

 

3 20 C.F.R. § 10.5(x).

4

Id.

5

Id.; Federal (FECA) Procedure Manual, Part 2 -- Claims, Recurrences, Chapter 2.1500.6a(4) (June 2013).

6 20 C.F.R. §§ 10.5(x), 10.104(c) and 10.509; see Federal (FECA) Procedure Manual, Part 2 -- Claims, Recurrences, 

Chapter 2.1500.2b.

7 Theresa L. Andrews, 55 ECAB 719, 722 (2004).
6

to the original injury.8 This burden includes the necessity of furnishing evidence from a qualified 

physician who concludes that the condition is causally related to the employment injury.9 The 

physician’s opinion must be based on a complete and accurate factual and medical history and 

supported by sound medical reasoning.10

When an injury arises in the course of employment, every natural consequence that flows 

from that injury likewise arises out of the employment, unless it is the result of an independent 

intervening cause attributable to claimant’s own intentional misconduct.11 Thus, a subsequent 

injury, be it an aggravation of the original injury or a new and distinct injury, is compensable if it 

is the direct and natural result of a compensable primary injury.12

Where an employee claims that a condition not accepted or approved by OWCP was due 

to an employment injury, he or she bears the burden of proof to establish that the condition is 

causally related to the employment injury.13

ANALYSIS

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

disability on October 7, 2015, causally related to her accepted March 18, 2014 employment injury.

Appellant argued that she could not perform her limited job duties because of consequential 

injuries to her back that resulted from her accepted knee condition. An x-ray dated October 7, 

2015 demonstrated an L4-5 anterolisthesis and decreased disc height at L5-S1. However, this 

diagnostic study does not address the etiology of appellant’s back conditions. Appellant also 

submitted evidence from physician’s assistants and physical therapists. These reports do not 

constitute competent medical evidence because these medical care providers are not considered 

“physician[s]” as defined under FECA.14 Certain healthcare providers such as physician assistants, 

nurse practitioners, physical therapists, and social workers are not considered “physician[s]” as 

 

8 20 C.F.R. § 10.104(b); see Federal (FECA) Procedure Manual, Part 2 -- Claims, Recurrences, Chapter 2.1500.5 

and 2.1500.6.

9 See S.S., 59 ECAB 315, 318-19 (2008).

10 Id. at 319.

11 Mary Poller, 55 ECAB 483, 487 (2004); 1 Arthur Larson & Lex K. Larson, Larson’s Workers’ Compensation 

Law 10-1 (2006).

12 Susanne W. Underwood (Randall L. Underwood), 53 ECAB 139, 141 n.7 (2001).

13 Jaja K. Asaramo, 55 ECAB 200, 204 (2004).

14 5 U.S.C. § 8101(2); Sean O’Connell, 56 ECAB 195 (2004) (physician’s assistants); Jennifer L. Sharp, 48 ECAB 

209 (1996) (physical therapists). See also Gloria J. McPherson, 51 ECAB 441 (2000); Charley V.B. Harley, 2 ECAB 

208, 211 (1949) (a medical issue such as causal relationship can only be resolved through the submission of probative 

medical evidence from a physician).
7

defined under FECA.15 Consequently, their medical findings and/or opinions will not suffice for 

purposes of establishing entitlement to FECA benefits.16 

Dr. Ditonto diagnosed possible lumbar radiculopathy with known disc disease and 

foraminal stenosis, possible facet syndrome, and ongoing knee pain status post trauma and surgery. 

However, his report does not provide an opinion regarding the cause of appellant’s current 

disability. 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.17 For 

these reasons, the Board finds that this evidence is insufficient to establish that appellant sustained 

a consequential injury.

In a December 22, 2015 report, Dr. Rauh noted that appellant experienced low back pain,

which he felt to be causally related to her knee secondary to favoring the left knee postoperatively. 

Similarly, Dr. Clark diagnosed cervicalgia, other intervertebral disc degeneration, lumbar region, 

and noted that appellant presented with low back pain and bilateral leg pain. She indicated that 

appellant had a work-related injury to her left knee on March 18, 2014 which had caused her to 

compensate on the right side and caused a consequential injury to her lumbar spine. Although 

disability resulting from surgery or treatment authorized by OWCP is compensable,18 Drs. Rauh 

and Clark have failed to provide sufficient medical rationale explaining how appellant’s accepted 

left knee condition caused or aggravated her back conditions. Therefore, the Board finds that this 

evidence is insufficient to establish appellant’s claim for a consequential back injury.

Appellant alleged that her recurrence of total disability was caused by an inability to 

perform her light-duty job requirements. However, the record shows that the modified licensed 

practical nurse position she accepted on June 10, 2015 indicated that the duties required 

“occasional stair climbing, standing, or walking limited to 12 hours, no bending, stooping, 

squatting, or kneeling, lifting limited to less than 10 pounds, pushing or pulling less than 10 

pounds, and sedentary work only.”

Further, appellant did not submit sufficient medical evidence to establish that her assigned 

duties had changed such that she was not medically able to perform them. She did not submit 

adequate medical evidence to support that her assigned duties exceeded her medical limitations or 

that she otherwise had a spontaneous change in her accepted left knee condition in the present 

claim. In his reports, Dr. Rauh released appellant to light-duty work with the following 

restrictions: walking and standing up to eight hours per day, no bending/stooping, pushing, 

pulling, and lifting no more than 10 pounds, and no squatting, kneeling, or climbing with 

occasional stair use. He failed to provide a rationalized medical opinion explaining how 

appellant’s assigned duties exceeded her physical limitations or caused or aggravated her accepted 

left knee condition. Dr. Rauh reported that appellant had a recent fall at work on April 5, 2016 

 

15 5 U.S.C. § 8101(2); 20 C.F.R. § 10.5(t).

16 K.W., 59 ECAB 271, 279 (2007); David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006). A report from a physician 

assistant or certified nurse practitioner will be considered medical evidence if countersigned by a qualified physician. 

Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3a(1) (January 2013).

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

18 See R.S., Docket No. 15-0576 (issued June 9, 2015).
8

and diagnosed ACL sprain of the left knee and on April 22, 2016 he diagnosed left knee 

exacerbation of preexisting arthritis, no clear evidence of interval ACL tear, possible new posterior 

horn lateral meniscus tear, and medial compartment arthritis due to a new history of injury to her 

left knee. However, OWCP has not accepted an April 5, 2016 employment incident in this case. 

The Board finds there is insufficient evidence to establish that appellant’s light-duty job 

requirements changed such that the job requirements were no longer within the restrictions 

provided by Dr. Rauh and appellant was unable to perform her limited-duty position.19

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 

disability on October 7, 2015 causally related to her accepted March 18, 2014 employment injury.

ORDER

IT IS HEREBY ORDERED THAT the December 13, 2016 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: December 4, 2018

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

 

19 See J.F., 58 ECAB 124 (2006); see also Terry R. Hedman, 38 ECAB 222 (1986).