United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

N.T., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS ADMINISTRATION MEDICAL 

CENTER, Minneapolis, MN, Employer

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Docket No. 18-1620

Issued: May 6, 2019

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 24, 2018 appellant filed a timely appeal from a July 12, 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

 

1 5 U.S.C. § 8101 et seq.

2 The Board notes that following the July 12, 2018 decision, OWCP received additional evidence. 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 her burden of proof to establish additional 

conditions including depression, anxiety, post-traumatic stress disorder, bilateral hip, and lower 

back conditions, causally related to her accepted November 10, 2009 employment injury.

FACTUAL HISTORY

On December 9, 2009 appellant, then a 33-year-old pharmacy technician, filed a traumatic 

injury claim (Form CA-1) alleging that on November 10, 2009 she injured her left knee after 

tripping over a stack of totes. She did not stop working. OWCP accepted the claim for left knee 

strain and authorized left kneecap repair/arthroscopic surgery, which occurred on July 26, 2012. 

It also authorized the removal of left support implant, which occurred on February 7, 2014 and 

total left knee arthroplasty, which occurred on January 21, 2015.3

By letter dated March 17, 2015 OWCP paid appellant compensation on the periodic rolls 

for temporary total disability with the first payment covering the period March 6 to April 4, 2015.

In a letter dated August 11, 2015, appellant requested that OWCP expand the acceptance 

of her claim to include consequential conditions, which included heart disease, sleep apnea, heart 

failure, Systemic Inflammatory Response Syndrome (SIRS), hypoxemia, cardiac dysrhythmias, 

acute respiratory failure, vascular comp vessel, esophageal reflux, arthropathy, long-term use of 

anticoagulants, joint replaced knee, abnormal serum enzyme level, and depressive disorder. She 

alleged that she sustained these conditions following approved total knee replacement surgery on 

January 21, 2015. 

In progress notes dated February 26, 2016, Dr. Katie Nixdorf, a physician Board-certified 

in neurology and pain medicine, provided examination findings. She diagnosed chronic left knee 

pain, left pain with mechanical and neuropathic features, abnormal gait, depression, ankle pain, 

lumbar radiculopathy, and sleep apnea, and left sacroiliac joint dysfunction and piriformis 

tenderness.

In a continuity of care document, Dr. Nixdorf noted that appellant was seen on March 7, 

2016 and provided examination findings. Diagnoses included major depressive disorder, recurrent 

episode, mild, ankle pain, gastroesophageal reflux disease (GERD), knee pain, and abnormal gait. 

As of November 11, 2015, Dr. Nixdorf found the condition of mild major depression resolved.

In a letter dated July 6, 2016, appellant again requested that the acceptance of her claim be 

expanded to include additional conditions. She stated that her work injury caused depression, 

anxiety, GERD, nerve pain, muscle spasms, hip conditions, sciatica, and right knee pain. 

Appellant alleged weight gain from the medications she has taken for her injury. She also 

requested that OWCP accepted Body Mass Index (BMI) over 40 as she wanted to have gastric 

bypass surgery.

 

3 By decision dated February 8, 2016, OWCP granted appellant a schedule award for 23 percent left lower extremity 

permanent impairment. 
3

In a July 12, 2016 report, Dr. Nixdorf reported that appellant was seen for pain complaints. 

She provided examination findings and reported no change in medical history. Dr. Nixdorf

diagnosed abnormal gait, chronic left knee pain, leg pain with mechanical and neuropathic 

features, sleep apnea, depression, and history of left sacroiliac joint dysfunction and piriformis 

tenderness.

By decision dated July 29, 2016, OWCP expanded acceptance of appellant’s claim to 

include the conditions of left leg and knee sprain, lower left leg joint pain, gait abnormality, left 

patella dislocation, limb cramp, and lower extremity venous embolism, and deep vessels 

thrombosis.4

Dr. Nixdorf, in progress notes dated August 30 and October 25, 2016, and February 7, 

2017, provided examination findings and diagnosed abnormal gait, chronic left knee pain, leg pain 

with mechanical and neuropathic features, sleep apnea, depression, and history of left sacroiliac 

joint dysfunction and piriformis tenderness. She noted that appellant was having gastric bypass 

surgery on October 3, 2016.

In progress notes dated February 7, 2017, Dr. Annie Burton, a physician Board-certified in 

anesthesiology and pain medicine, provided examination findings. She diagnosed abnormal gait, 

chronic left knee pain, leg pain with mechanical and neuropathic features, sleep apnea, depression, 

and history of left sacroiliac joint dysfunction and piriformis tenderness.

In reports dated March 12 and May 8, 2017, John Patrick O’Laughlin, Ph.D., a clinical 

psychologist, reported appellant that had been involved in a motor vehicle accident requiring 

hospitalization for head trauma. Appellant complained of anxiety, neck and head pain, and 

extreme headaches. She also reported having panic attacks. Dr. O’Laughlin found appellant’s

pain had been aggravated by her nonwork-related automobile accident.

In a May 12, 2017 report, Dr. Nixdorf provided examination findings unchanged from 

prior reports. She diagnosed chronic left knee pain, abnormal gait, depression, leg pain with 

neuropathic and mechanical features, sleep apnea, morbid obesity, mild-to-moderate concussion, 

headaches of cervicogenic nature and sacroiliac joint dysfunction, and piriformis syndrome.

Dr. O’Laughlin, in a June 12, 2017 report, noted appellant’s complaints of chronic knee 

pain, cervicalgia due to a motor vehicle accident, and significant right hip pain.

In progress notes dated July 5, 2017, Dr. O’Laughlin reported that appellant complained of 

headaches, moderate worsening of her knee pain, and stress from her workload.

Dr. Nixdorf, in progress notes dated July 11, 2017, noted examination findings. She 

reported that, since the last examination on May 12, 2017, appellant had been involved in an 

automobile accident where she was rear-ended at a stoplight and her car was totaled. Dr. Nixdorf 

diagnosed abnormal gait, chronic left knee pain, leg pain with mechanical and neuropathic 

features, sleep apnea, depression, sacroiliac joint dysfunction and piriformis tenderness, mild-to-

 

4 By decision dated February 8, 2016, OWCP granted appellant a schedule award for a 23 percent left lower 

extremity permanent impairment, which ran for 66.24 weeks from January 23, 2016 to April 30, 2017.
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moderate concussion from involvement in an automobile accident with residual memory loss and 

visual issues, and headaches of a cervicogenic nature.

In notes dated September 6, 2017, Dr. O’Laughlin reported appellant had post-concussion 

symptoms involving visual issues and headaches, which were interacting with work stress. 

Appellant related that she suffered from confusion and anxiety symptoms as well as other postconcussion symptoms.

Dr. O’Laughlin, in October 11, 2017 notes, reported that appellant complained of knee and 

back pain and headaches. He attributed her headache to occipital headache from her automobile 

accident. Appellant stated while her pain had increased that she was more stress about her return 

to work and the pressure to resume full-time work.

On October 17, 2017 appellant was seen by Dr. Nixdorf for complaints of pain. 

Dr. Nixdorf diagnosed headaches of a cervicogenic nature, mild-to-moderate concussion from a 

motor vehicle accident, residual memory and visual loss from the concussion, depression, 

sacroiliac joint dysfunction and piriformis syndrome, leg pain with mechanical and neuropathic 

features, and chronic left knee pain.

In a November 14, 2017 standard diagnostic assessment report, Dr. David E. Adson 

evaluated appellant for post-concussion syndrome. His diagnoses included recurrent major 

depressive disorder, panic disorder, post-traumatic stress disorder, generalized anxiety disorder, 

somatic symptom disorder with predominant pain, history of conversion disorder, and opioid use 

disorder. Dr. Adson reported that appellant had a long history of anxiety and depression and had 

been doing well until her March 2017 automobile accident. He opined that appellant’s problem 

was a combined depression and post-concussion syndrome.

In a February 6, 2018 report, Dr. Nixdorf continued to diagnose chronic left knee pain, 

abnormal gait, depression, leg pain with neuropathic and mechanical features, sleep apnea, morbid 

obesity, mild-to-moderate concussion, headaches of cervicogenic nature, and sacroiliac joint 

dysfunction and piriformis syndrome.

On April 30, 2018 appellant requested that OWCP expand the acceptance of her claim to 

include depression, anxiety, post-traumatic stress disorder, bilateral hip osteoarthritis, and lower 

back pain as consequential injuries. She alleged that she developed severe depression from posttraumatic stress disorder and the constant pain she experienced prior to being diagnosed with left 

knee dislocation. Appellant also alleged that, as a result of the misdiagnosis of her left knee 

condition, her back and hips were impacted. She further alleged that, as the result of a heavy work 

load, she developed anxiety. 

In a May 30, 2018 development letter, OWCP informed appellant that the evidence of 

record was insufficient to warrant expansion of the acceptance of her claim to include the 

conditions she identified. It noted that her depression and anxiety were preexisting conditions, 

which dated back to when she attended college and referenced a November 10, 2009 report. 

OWCP also noted that in March 2017 appellant had been involved in a motor vehicle accident,

which resulted in a diagnosis of postconcussion syndrome and anxiety. It advised her as to the
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medical and factual evidence required to support her request for expansion of her accepted 

conditions. OWCP afforded appellant 30 days to submit the requested evidence.

In response to OWCP’s request, appellant submitted undated statements, noting that her 

depression began in 1996 while at college due to homesickness, but had been management by 

medication. She related that due to the pain from her work injury she became very depressed. 

Additionally, prior to her work injury she had been very active. Next, appellant related that as a 

result of her March 18, 2017 motor vehicle accident she sustained a traumatic brain injury, which 

created a lot of anxiety. She stated that, prior to the motor vehicle accident, her anxiety had been 

at a high level, which she attributed to having to perform the work of three people.5

By decision dated July 12, 2018, OWCP denied appellant’s request to expand the 

acceptance of her claim to include depression, anxiety, post-traumatic stress disorder, lower back 

pain, and bilateral hip osteoarthritis as causally related to her November 10, 2009 work injuries.

LEGAL PRECEDENT

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.6 

To establish causal relationship between the condition as well as any attendant disability 

claimed and the employment injury, an employee must submit rationalized medical evidence based 

on a complete medical and factual background supporting causal relationship.7 Causal relationship 

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

medical evidence.8 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.9 Neither the mere fact that a disease 

or condition manifests itself during a period of employment, nor the belief that the disease or 

condition was caused or aggravated by employment factors or incidents is sufficient to establish 

causal relationship.10

 

5 To the extent that appellant is alleging new employment factors, i.e., overwork, as causing or aggravating her 

anxiety, this could be considered a new occupational disease claim.

6 See T.E., Docket No. 18-1595 (issued March 13, 2019); T.F., Docket No. 17-0645 (issued August 15, 2018); 

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

7 S.A., Docket No. 18-0399 (issued October 16, 2018); M.W., 57 ECAB 710 (2006); John D. Jackson, 55 ECAB 

465 (2004).

8 Y.C., Docket No. 17-1938 (issued January 7, 2019); D.E., 58 ECAB 448 (2007); Mary J. Summers, 55 ECAB 

730 (2004).

9 F.H., Docket No. 18-1238 (issued January 18, 2019); P.M., Docket No. 18-0287 (issued October 11, 2018); 

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

10 H.R., Docket No. 18-0640 (issued V.W., 58 ECAB 428 (2007); Ernest St. Pierre, 51 ECAB 623 (2000).
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ANALYSIS

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

emotional, bilateral hip, and lower back conditions as causally related to her accepted 

November 10, 2009 employment injury.

Dr. O’Laughlin, in reports dated March 12 and May 8, 2017, opined that appellant’s pain 

had been aggravated by her nonwork-related automobile accident. In a June 12, 2017 report, he 

noted appellant’s complaints of stress from her workload, headache, and moderate worsening of

right knee pain. On September 6, 2017 Dr. O’Laughlin noted that appellant’s work stress was 

interacting with her headaches and visual issues. As he did not attribute appellant’s conditions to 

the November 10, 2009 employment injury, his opinion is of diminished probative value.11 Thus, 

the reports from Dr. O’Laughlin are insufficient to support appellant’s request to expand the 

acceptance of her claim.

The remaining medical evidence is also insufficient to warrant expansion of the acceptance 

of appellant’s claim. Dr. Nixdorf’s diagnoses included sleep apnea, mild-to-moderate concussion, 

cervicogenic headaches, left sacroiliac joint dysfunction and piriformis syndrome, depression, and 

lumbar radiculopathy. Dr. Burton diagnosed history of left sacroiliac joint dysfunction, piriformis 

tenderness, depression, and sleep apnea. Dr. Adson diagnosed post-traumatic stress disorder, 

recurrent major depressive disorder, panic disorder, opioid use disorder, and conversion disorder. 

No opinion was offered as to the cause of the diagnosed conditions by Dr. Adson, Dr. Burton, or

Dr. Nixdorf. Medical evidence offering no opinion regarding the cause of an employee’s condition 

is of no probative value on the issue of causal relationship.12 None of these physicians provided a 

rationalized opinion warranting expansion of appellant’s claim. Therefore these reports are 

insufficient to establish appellant’s claim.

Appellant failed to provide reasoned medical evidence demonstrating that her 

November 10, 2009 employment injury caused or aggravated her depression, anxiety, posttraumatic stress disorder, bilateral hip, and lower back. Accordingly, the Board finds that she has 

not met her burden of proof to establish expansion of the accepted conditions of her claim.

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 additional 

conditions including depression, anxiety, post-traumatic stress disorder, bilateral hip, and lower 

back conditions, causally related to her accepted November 10, 2009 employment injury.

 

11 See F.H., supra note 10; C.H., Docket No. 17-0266 (issued May 17, 2018).

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

IT IS HEREBY ORDERED THAT the July 12, 2018 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: May 6, 2019

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