United States Department of Labor

Employees’ Compensation Appeals Board

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K.C., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Bedford Park, IL, Employer

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Docket No. 18-0234

Issued: September 14, 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

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On November 13, 2017 appellant filed a timely appeal from a July 20, 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 case. 

ISSUE

The issue is whether appellant met her burden of proof to establish that her complex 

regional pain syndrome (CRPS) was a consequence of her accepted conditions of left tarsal tunnel 

syndrome, left plantar fibromatosis, and lumbar sprain. 

FACTUAL HISTORY

On September 7, 2012 appellant, then a 45-year-old window clerk, filed an occupational 

disease claim (Form CA-2) alleging that as a result of standing at the retail window on a concrete 

 

1 5 U.S.C. § 8101 et seq. 
2

floor she sustained left foot nerve damage, plantar fascia, fractures, joint separation, and 

inflammation. OWCP accepted her claim for left tarsal tunnel syndrome, left plantar fibromatosis, 

and lumbar sprain.2 

Appellant stopped work intermittently and returned to part-time light duty. OWCP initially 

paid her wage-loss compensation benefits on the supplemental rolls and, effective 

February 10, 2013, it converted her wage-loss compensation and medical benefits to the periodic 

rolls. 

Dr. Daniel Luetkehans, a podiatric surgeon, performed multiple surgeries including a 

February 16, 2012 release of tibial nerve in the left medial calcaneal branch with a tarsal tunnel 

release, a September 19, 2012 removal of screws and plate, a May 20, 2014 resection of joint with 

arthrodesis of left calcaneal cuboid joint, and a May 17, 2016 removal of plates and screws. 

Dr. Luetkehans also referred appellant to other physicians for treatment. On March 8, 2013

he referred her to Dr. Drason Gastezski, a physician Board-certified in anesthesiology and pain 

medicine, for an evaluation of CRPS. In a March 25, 2013 report, Dr. Gastevski diagnosed: 

(1) left lower extremity CRPS; (2) right low lumbar facet arthropathy with axial low back pain; 

and (3) bilateral paraspinous muscle spasm with myofascial pain. He proceeded to treat appellant 

with a series of injections through March 14, 2014. Dr. Faris Abusharif, a physician specializing

in anesthesiology and interventional pain management, began treating her on August 20, 2014. He 

diagnosed appellant with CRPS, and treated her with injections. 

In a letter dated November 8, 2016, appellant asked that her claim be expanded to include 

the condition of CRPS. She stated that, after multiple surgeries on her left foot, she had sustained 

nerve damage from the nerve being wrapped around the hardware plate that was inserted into her 

foot for approximately one year. 

In a November 8, 2018 medical report, Dr. Luetkehans opined that the diagnosis of CRPS

should be an accepted condition as it was related to appellant’s original work injury. He 

summarized his treatment of her. Dr. Luetkehans noted that appellant was originally injured at 

work as a postal worker. He indicated that she eventually had surgery with an arthrodesis of the 

fourth and fifth metatarsocuboid joint with internal fixation of the left foot. Dr. Luetkehans 

referred appellant to Dr. Gastezski for evaluation of CRPS on March 8, 2013. He noted that she

had two sympathetic blocks for diagnosed CRPS and initially had 100 percent relief of her 

symptoms of CRPS, but she then suffered a recurrence. Dr. Luetkehans opined that, as appellant 

had relief of her pain following the injections, he determined that she had CRPS and this was 

related to her original work injury. He noted that she was still being treated for CRPS by

Dr. Abusharif. 

On November 30, 2016 OWCP referred appellant’s record to OWCP’s medical adviser for 

a determination as to whether she had CRPS and, if so, whether it was a consequence of the 

 

2 Appellant had a prior employment-related claim, in OWCP File No. xxxxxx593, that OWCP accepted for lumbar 

sprain which occurred on July 12, 2011 while she was lifting heavy boxes. This case is open for medical treatment 

only. OWCP administratively combined OWCP File No. xxxxxx593 with the current claim, OWCP File No. 

xxxxxx046, with the latter serving as the master file.
3

accepted, work-related injury. In a reply dated December 20, 2016, Dr. Arnold T. Berman, a 

Board-certified orthopedic surgeon and OWCP’s medical adviser, noted that appellant did have 

ongoing clinical difficulties with regard to her left foot, but that they were due to surgical 

complications and she definitely did not meet the diagnostic criteria for CRPS citing the sixth

edition of the American Medical Association, Guides to the Evaluation of Permanent Impairment,

(A.M.A., Guides)

3 Table 15-24, Diagnostic Criteria for Complex Regional Pain Syndrome, and 

Table 15-25, Objective Diagnostic Criteria Points for Complex Regional Pain Syndrome.

4

 He 

noted that, while appellant certainly had pain complaints and weakness as a result of multiple

operations, the objective criteria listed in Table 15-25 had not been met. Dr. Berman noted, inter 

alia, that there were no atrophic changes, and no vasomotor changes in skin color or symmetry. 

Therefore, he determined that the diagnosis of CRPS could not be made and the acceptance of the

claim should not be expanded to include CRPS. Dr. Berman also noted that the surgical indications 

were questionable. He noted that there had been at least four operative procedures, and that each 

was highly questionable with regard to indications as well as specific choice of operative 

procedures and techniques. Dr. Berman noted that all surgeries were done by a podiatrist without 

any orthopedic consultation. He indicated that conservative measures were not utilized for the 

fullest extent prior to surgical intervention and therefore the claimant’s clinical management did 

not meet the standard of care. Dr. Berman concluded that the mechanism of injury, the surgery,

and subsequent events were not competent to produce CRPS, and that the reasons for the 

neurogenic pain was complications of the surgical intervention.

In an April 11, 2017 report, Dr. Luetkehans responded to the report of Dr. Berman. He 

alleged that Dr. Berman appeared to be biased against podiatric surgeons. Dr. Luetkehans 

indicated that it did not appear that Dr. Berman had any specialty in foot and ankle conditions. He

noted that he had been in practice for 26 years after completing a residency in foot and ankle 

surgery. Dr. Luetkehans further noted that he was Board-certified by the American Board of Foot 

and Ankle Surgery in rear foot reconstruction and ankle surgery. He also noted that he was Boardcertified in wound management. As to the medical question at issue, Dr. Luetkehans opined that 

appellant met the criteria for CRPS. He noted that she had hyperesthesia and allodynia, vasomotor 

changes and skin changes, decreased range of motion, chronic edema, and temperature changes. 

Dr. Luetkehans further noted that he referred appellant to Dr. Gastevski who treated her with 

injections and that she responded well to the injections and had an increase in skin temperature to 

the left foot. He noted that this is pathognomonic for CRPS. Dr. Luetkehans opined that no 

additional imaging or testing was warranted if the sympathetic injections was positive. He noted 

that appellant had nonsurgical treatment prior to surgical intervention. Dr. Luetkehans contended 

that Dr. Berman’s comment that the typical mechanism for injury for CRPS/reflex sympathetic 

dystrophy was a crush injury was simply untrue, and that CRPS often followed trivial injuries or 

was a complication of surgery, as occurred in her case. He noted that appellant has been treated 

by Dr. Gastevski for CRPS and Dr. Abusharif for pain treatment and additional sympathetic blocks 

for CRPS, so two pain specialists had treated her for CRPS. Dr. Luetkehans concluded that she

met the criteria for CRPS which was a complication and consequence following surgery that was 

approved by OWCP for the accepted work-related injury, and asked that CRPS be added to the 

 

3 A.M.A., Guides (6th ed. 2009).

4

Id. at 453-54. 
4

approved diagnoses. In a November 8, 2016 letter, he reiterated that appellant was being treated 

for CRPS related to her original work injury. 

On April 27, 2017 OWCP determined that a conflict in medical opinion existed between 

appellant’s physician, Dr. Luetkehans, and OWCP’s medical adviser, Dr. Berman, as to whether 

the claimed CRPS was consequentially related to, aggravated, or accelerated by the accepted 

conditions. OWCP prepared a new statement of accepted facts (SOAF) on April 27, 2017 wherein 

it listed appellant’s accepted conditions as left foot tarsal tunnel syndrome, plantar fibromatosis, 

and lumbar sprain. 

On May 24, 2017 OWCP referred appellant, along with the SOAF, to Dr. Matthew L. 

Jimenez, a Board-certified orthopedic surgeon, for an impartial medical examination. In a June 29, 

2017 impartial medical opinion, Dr. Jimenez conducted a physical examination and reviewed her

records. He determined that appellant did not have a work-related injury that was documented. 

Dr. Jimenez noted that there was no evidence of any event or issue at work that met the criteria for 

work-related injury and she clearly had multiple surgeries many of which he believed were 

unnecessary. Therefore, he opined that none of appellant’s symptoms at this point were related in 

any way to any alleged work-related event, but clearly related to her multiple surgeries. 

Dr. Jimenez also determined that she did not have CRPS and that if she did it was not employment 

related. He explained that appellant did not have clinical or radiographic evidence of CRPS. 

Dr. Jimenez also noted that he did not believe that any diagnostic test at this point would be useful. 

He did note that appellant had evidence of fusions in her midfoot regions and they had created a 

symptom complex, which was permanent, but this symptom complex was not work related and 

was instead related to what appears to be unnecessary surgeries. Dr. Jimenez noted that she did

have significant disability including loss of motion in her hindfoot and midfoot, and permanent 

scars and numbness and tingling in her nerve distribution related to the multiple surgeries that she 

had undergone. 

By decision dated July 20, 2017, OWCP denied expansion of the acceptance of appellant’s 

claim to include CRPS. It found that, pursuant to the opinion of the impartial medical examiner, 

the medical evidence did not demonstrate that weakness or impairment caused by her accepted 

work-related injury or illness led to an aggravation of the original injury or to a new injury as 

required for coverage under FECA. 

LEGAL PRECEDENT

It is an accepted principle of workers’ compensation law that when the primary injury is 

shown to have arisen out of the course of employment, every natural consequence that flows from 

the injury is deemed to arise out of the employment, unless it is the result of an independent 

intervening cause attributable to the employee’s own intentional conduct.5 In discussing the range

of compensable consequences, once the primary injury is causally connected with the employment, 

 

5 Albert F. Ranieri, 55 ECAB 598, 602 (2004). 
5

then a subsequent injury, whether 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.6

The Board has held that, if a member weakened by an employment injury contributed to a 

later injury, the subsequent injury will be compensable as a consequential injury if the further 

medical complication flows from the compensable injury so long as it is clear that the real operative 

factor is the progression of the compensable injury.7

A claimant bears the burden of proof to establish a claim for a consequential injury.

8

 As 

part of this burden, he or she must present rationalized medical opinion evidence showing causal 

relationship.9 Causal relationship is a medical issue and the medical evidence generally required 

to establish causal relationship is rationalized medical opinion evidence.10 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.11

Section 8123(a) of FECA provides that, if there is a disagreement between an OWCPdesignated physician and the employee’s physician, OWCP shall appoint a third physician (known 

as a referee physician or impartial medical specialist) who shall make an examination.12 This is 

called a referee examination and OWCP will select a physician who is qualified in the appropriate 

specialty and who has no prior connection with the case.13 For a conflict to arise, the opposing 

physician’s viewpoints must be of “virtually equal weight and rationale.14 Where OWCP has 

referred the case to an impartial medical examiner to resolve a conflict in the medical evidence, 

the opinion of such specialist, if sufficiently well-reasoned and based upon a proper factual 

background, must be given special weight.15

 

6 Charles W. Downey, 54 ECAB 421-23 (2003). 

7 S.M., 58 ECAB 166 (2008); Raymond A. Nester, 50 ECAB 173, 175 (1998); see also M.M., Docket No. 17-1532 

(issued January 23, 2018). 

8 S.E., Docket No. 17-1601 (issued January 19, 2018). 

9

Id.

10 I.R., Docket No. 09-1229 (issued February 24, 2010); D.I., 59 ECAB 158 (2007). 

11 I.J., 59 ECAB 408 (2008); Ruthie M. Evans, 41 ECAB 416 (1990). 

12 5 U.S.C. § 8123(a); 20 C.F.R. § 10.32(b). See R.S., Docket No. 10-1704 (issued May 13, 2011); S.T., Docket 

No. 08-1675 (issued May 4 2009) (the district medical adviser, acting on behalf of OWCP, may create a conflict in 

medical opinion). 

13 20 C.F.R. § 10.321. 

14 Darlene R. Kennedy, 57 ECAB 414, 416 (2006). 

15 Gary R. Sieber, 46 ECAB 215, 225 (1994). 
6

ANALYSIS

The Board finds that this case is not in posture for decision due to an unresolved conflict 

in the medical evidence. 

OWCP accepted appellant’s claim for left tarsal tunnel syndrome, left plantar fibromatosis, 

and lumbar sprain. Appellant then requested that her claim be expanded to include CRPS. By 

decision dated July 20, 2017, OWCP denied expansion of the acceptance of her claim. 

Appellant’s treating physicians, Dr. Luetkehans, Dr. Gastevski, and Dr. Abusharif, found 

that appellant had CRPS and treated her with injections and surgery. Dr. Berman, OWCP’s

medical adviser opined that she did not meet the criteria for a diagnosis of CRPS as set forth in the 

A.M.A., Guides. He further noted that appellant’s surgeries were questionable. Due to the conflict 

in medical opinion with regard to whether she had CRPS, on May 24, 2017 OWCP referred her to

Dr. Jimenez for an impartial medical examination, along with a SOAF, a list of specific questions, 

and the medical record. In the SOAF, OWCP noted that it accepted appellant’s claim for left tarsal 

tunnel syndrome and left plantar fibromatosis, and lumbar sprain. It noted that these conditions 

were sustained due to her repetitive motion and as a result of standing on concrete floors. 

Dr. Jimenez did not rely on the SOAF when formulating his opinion. He premised his 

report on the fact that appellant did not have a work-related injury that was documented, despite 

the fact that the SOAF clearly indicated that herstanding on concrete floors during her employment

caused her left tarsal tunnel syndrome, left plantar fibromatosis, and lumber sprain.16 Dr. Jimenez

disregarded the findings of the SOAF and did not rely on this document for determination with 

regard to her CRPS. The Board finds that his report is of diminished probative value as the opinion 

disregarded critical elements of the SOAF and is therefore flawed.17 The Board notes that it is the 

function of a medical expert to give an opinion only on medical questions, not to find facts.18 

To be given special weight, an opinion of an impartial medical specialist must be based on 

a proper factual background and medical opinion based on an incomplete or inaccurate history are 

of limited probative value.19 Furthermore, Dr. Jimenez concluded that appellant’s symptoms were 

causally related to her unwarranted surgeries. However, residuals resulting from surgery or

treatment authorized by OWCP are compensable.20

 

16 See N.C., Docket No. 15-1855 (issued June 3, 2016) (the Board reversed OWCP’s termination of the claimant’s 

wage-loss compensation and medical benefits because it had relied on the opinion of the impartial medical examiner 

who determined that the claimant merely sustained soft tissue injuries as a result of two employment incidents, instead 

of the accepted conditions in the SOAF which included lumbosacral radiculitis of the lower extremities, lumbar 

acquired spondylolisthesis, and L5 spondylosis). 

17 P.S., Docket No. 15-0253 (issued May 22, 2015). 

18 Paul King, 54 ECAB 356 (2003). Furthermore, to be given special weight, the opinion of an impartial medical 

specialist must be based on a proper factual background.

19 M.R., Docket No. 17-0634 (issued July 24, 2018). 

20 See M.P., Docket No. 15-0361 (issued September 27, 2016). 
7

As the conflict between appellant’s physicians, including Dr. Luetkehans, and OWCP’s

medical adviser, Dr. Berman, remains unresolved, the case will be remanded to OWCP for 

selection of a new impartial medical specialist to evaluate whether appellant has CRPS and 

whether this condition is causally related to her federal employment. Following this and other 

development deemed necessary, OWCP shall issue a de novo decision in this case. 

CONCLUSION

The Board finds that this case is not in posture for decision.

ORDER

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

Programs dated July 20, 2017 is set aside, and this case is remanded to OWCP for further 

development consistent with this decision. 

Issued: September 14, 2018

Washington, DC

Christopher J. Godfrey, 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