United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

T.H., Appellant

and

SOCIAL SECURITY ADMINISTRATION, 

Baltimore, MD, Employer

__________________________________________

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Docket No. 19-1891

Issued: April 3, 2020

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

CHRISTOPHER J. GODFREY, Deputy Chief Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On September 12, 2019 appellant filed a timely appeal from an August 2, 2019 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.

ISSUE

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

causally related to the accepted January 25, 2019 employment incident.

FACTUAL HISTORY

On March 14, 2019 appellant, then a 33-year-old Information Technology manager, filed 

a traumatic injury claim (Form CA-1) alleging that on January 25, 2019 she injured her right arm 

while in the performance of duty. She explained that as she was walking from her car into the 

 

1

5 U.S.C. § 8101 et seq.
2

building she slipped and fell on a patch of ice on the sidewalk and injured her right arm. Appellant 

did not stop work.

In a March 28, 2019 medical report, Dr. Daniel Redziniak, a Board-certified orthopedic 

surgeon, noted that appellant presented with right shoulder pain after slipping on ice and landing 

on her outstretched right upper extremity. Appellant denied a history of injury to her right 

shoulder. Dr. Redziniak recorded an impression of a right shoulder rotator cuff pathology and 

diagnosed acute pain of the right shoulder. In a workers’ compensation case report of even date, 

he referred appellant to physical therapy to treat her right shoulder pain.

Appellant submitted physical therapy notes dated from May 7 to June 6, 2019, by Daniel 

Sullivan and Josephine Gosnell, physical therapists, detailing treatment of her right shoulder pain.

In a development letter dated June 25, 2019, OWCP informed appellant that her claim 

initially appeared to be a minor injury that resulted in minimal or no lost time from work and that 

continuation of pay was not controverted by the employing establishment, and thus, limited 

expenses had therefore been authorized. However, a formal decision was now required. OWCP 

provided a factual questionnaire inquiring about the circumstances surrounding appellant’s

claimed injury for her completion and requested that she submit a narrative medical report from 

her physician, which contained a detailed description of findings and diagnoses, explaining how 

the reported incident caused or aggravated her medical condition. It afforded her 30 days to 

respond. In a separate development letter of even date, OWCP requested that the employing 

establishment provide comments from a knowledgeable supervisor regarding the accuracy of 

appellant’s allegations.

In response, appellant submitted a January 25, 2019 medical note from the employing 

establishment’s employee health center with an illegible signature which noted that appellant 

slipped on black ice and fell on her right arm. The note indicated that her arm was sore and tender 

to the touch and that she could hear a clicking noise when she rotated her right arm. The note 

further indicated that appellant was advised to use pain medication and ice to treat the pain in her 

right arm. 

Appellant also submitted a copy of a text message conversation from the date of injury

between her and L.C., a coworker, in which she informed L.C. that she fell on the ice over by the 

daycare.

In response to OWCP’s questionnaire, appellant explained that, on January 25, 2019, she 

was walking from the parking lot to the building, when she slipped on a patch of ice on the sidewalk 

and fell on her right arm. She described experiencing soreness, tenderness, and throbbing daily in 

her right arm after the incident and undergoing medical treatment.

Appellant also submitted additional physical therapy notes dated from June 18 to 

July 23, 2019.

By decision dated August 2, 2019, OWCP denied appellant’s traumatic injury claim, 

finding that although she established that the January 25, 2019 incident occurred as alleged, she 

had failed to submit medical evidence containing a medical diagnosis in connection with her 
3

injury. It concluded, therefore, that the requirements had not been met to establish an injury as 

defined under FECA.

LEGAL PRECEDENT

An employee seeking benefits under FECA2 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 of FECA,3that 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 employment injury.4 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.5

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

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

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

form of medical evidence, to establish that the employment incident caused a personal injury. 6

ANALYSIS

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

condition causally related to the accepted January 25, 2019 employment incident.

In his March 28, 2019 medical report, Dr. Redziniak recorded an impression of a right 

shoulder rotator cuff pathology and diagnosed acute pain of the right shoulder due to her 

January 25, 2019 fall. He did not, however, provide a specific diagnosis of a medical condition of 

the right shoulder or right rotator cuff. The Board has held that the assessment of pain is not 

considered a diagnosis, as pain merely refers to a symptom of an underlying condition.7 A medical

report lacking a firm diagnosis and a rationalized medical opinion regarding causal relationship is 

 

2

Id.

3

J.P., Docket No. 19-0129 (issued April26, 2019); S.B., Docket No. 17-1779 (issued February 7, 2018); Joe D. 

Cameron, 41 ECAB 153 (1989).

4

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

ECAB 312 (1988).

5 R.R., Docket No. 19-0048 (issued April25, 2019); L.M., Docket No. 13-1402 (issued February 7, 2014); 

DeloresC. Ellyett, 41 ECAB 992 (1990).

6K.L., Docket No. 18-1029 (issued January9, 2019); see 5 U.S.C. § 8101(5) (injury defined); 20 C.F.R. §§ 10.5(ee), 

10.5(q) (traumatic injury and occupational disease defined, respectively).

7 M.V., Docket No. 18-0884 (issued December 28, 2018). The Board has consistently held that pain is a symptom, 

rather than a compensable medical diagnosis. See P.S., Docket No. 12-1601 (issued January 2, 2013); C.F., Docket 

No. 08-1102 (issued October 10, 2008).
4

of no probative value.8 Therefore, Dr. Redziniak’s report is insufficient to establish appellant’s 

claim.

Appellant also submitted physical therapy notes dated from May 7 to July 23, 2019. The 

Board has held that treatment notes signed by a physical therapist9 are not considered medical 

evidence as these providers are not considered “physician[s]” as defined under FECA.10 

Therefore, these notes lack probative value and are insufficient to establish appellant’s claim.

A January 25, 2019 medical note with an illegible signature noted that appellant 

experienced pain in her right arm after slipping on black ice and landing on her right arm. The 

Board has held that a report that is unsigned or bears an illegible signature lacks proper 

identification and cannot be considered probative medical evidence. Further, as previously noted, 

pain is not considered a valid diagnosis, as pain merely refers to a symptom of an underlying 

condition.11 For these reasons, the January 25, 2019 medical note is also insufficient to establish 

appellant’s burden of proof.

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

sufficient to establish a medical condition causally related to the accepted January 25, 2019 

employment incident.12 Appellant, therefore, has not met her 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 her burden of proof to establish a diagnosed 

medical condition causally related to the accepted January 25, 2019 employment incident.

 

8 P.C., Docket No. 18-0167 (issued May 7, 2019).

9 V.W., Docket No. 16-1444 (issued March 14, 2017).

10 See David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006) (lay individuals such as physician assistants, nurses, and 

physical therapists are not competent to render a medical opinion under FECA); 5 U.S.C. § 8101(2) (this subsection 

defines a “physician” as surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and 

osteopathic practitioners within the scope of their practice as defined by State law); see also D.J., DocketNo. 18-0593 

(issued February 24, 2020) (physical therapists are not physicians under FECA).

11 Supra note 8.

12 See T.J., Docket No. 18-1500 (issued May 1, 2019); see D.S., Docket No. 18-0061 (issued May 29, 2018).
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ORDER

IT IS HEREBY ORDERED THAT the August 2, 2019 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: April 3, 2020

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Christopher J. Godfrey, Deputy Chief Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board