United States Department of Labor

Employees’ Compensation Appeals Board

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L.C., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

SOUTHERN ARIZONA VETERANS 

ADMINISTRATION HEALTH CARE SYSTEM, 

Tucson, AZ, Employer

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Docket No. 19-0564

Issued: September 16, 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

JANICE B. ASKIN, Judge

ALEC J. KOROMILAS, Alternate Judge

JURISDICTION

On January 16, 2019 appellant filed a timely appeal from a July 27, 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 27, 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 greater than 13 

percent permanent impairment of the right upper extremity, for which she previously received a 

schedule award.

FACTUAL HISTORY

On November 3, 2011 appellant, then a 51-year-old medical supply technician, filed a 

traumatic injury claim (Form CA-1) alleging that on October 25, 2011 she punctured her right 

index finger on a small metal protrusion as she grabbed a metal pan filled with sterilized 

instruments while in the performance of duty. On October 29, 2011 she underwent surgical release 

of first annular (A1) pulley, release flexor tendon sheath, incision and drainage of abscess and 

drainage of tenosynovitis. Appellant returned to light-duty work on December 6, 2011. She 

returned to regular duty on January 4, 2012. On January 31, 2012 OWCP accepted appellant’s

claim for open wound of the right finger with complications and infection. 

In a June 14, 2012 note, appellant’s physician, Dr. Warren Breidenbach, a Board-certified 

plastic surgeon, released her from his care and diagnosed symptom magnification and possible 

mild irritation at the A1 pulley. He found that she had no permanent impairment, and that she 

could perform full-duty work. On January 16, 2013 Dr. Breidenbach performed surgery for saddle 

deformity of the right index finger. Based on his restrictions appellant returned to work on 

April 1, 2013 in an “alternative work assignment.” She returned to regular duty on 

April 25, 2013.3

On October 27, 2014 OWCP referred appellant, a statement of accepted facts (SOAF) and 

a series of questions for a second opinion evaluation with Dr. Mark E. Frankel, a Board-certified 

orthopedic surgeon. In his November 12, 2014 report, Dr. Frankel diagnosed reflex sympathetic 

dystrophy (RSD) or complex regional pain syndrome (CRPS) due to appellant’s accepted 

employment injury and found that she had not reached maximum medical improvement (MMI). 

On January 22, 2015 OWCP expanded acceptance of appellant’s claim to include RSD of the right 

upper extremity.

On May 7, 2016 appellant filed a claim for a schedule award (Form CA-7). 

In a June 9, 2016 development letter, OWCP requested additional medical evidence 

supporting that her accepted conditions were permanent and stationary as well as an impairment 

rating pursuant to the sixth edition of the American Medical Association, Guides to the Evaluation 

of Permanent Impairment (A.M.A., Guides).

4

 

3 On June 18, 2014 appellant filed a notice of recurrence (Form CA-2a) alleging that since her original injury on 

October 25, 2011 she had experienced continuous pain in the right index finger. She attributed her current condition 

of chronic pain and reflex sympathetic dystrophy (RSD) to her accepted October 25, 2011 employment injury. By 

decision dated September 17, 2014, OWCP denied appellant’s recurrence claim. Appellant requested reconsideration 

on October 14, 2014. By decision dated January 22, 2015, OWCP accepted her recurrence claim.

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

On August 19, 2016 OWCP referred appellant, a SOAF, and a list of questions for a second 

opinion evaluation with Dr. John R. Klein, a Board-certified orthopedic surgeon. In his 

December 1, 2016 report, Dr. Klein listed appellant’s physical findings including numbness on the 

ulnar aspect of the second finger and on the radial aspect of the third finger. He found no evidence 

of temperature asymmetry or skin color changes. Dr. Klein reported edema, but no sweating 

asymmetry. He found slightly decreased range of motion (ROM) of the index finger with flexion 

and weakness of the intrinsic muscles. Dr. Klein also reported that appellant’s bone scan was 

consistent with RSD. Applying the diagnosis-based impairment (DBI) estimates of the A.M.A., 

Guides for CRPS found in Table 15-24 he noted that based on Table 15-25 at least six points were 

positive. Dr. Klein assigned a grade modifier for functional history (GMFH) as 3, a grade modifier 

for physical examination (GMPE) as 2, and noted that a grade modifier for clinical studies (GMCS) 

were confirmatory for CRPS and concluded that the grade would be C after applying the net 

adjustment formula. He determined that appellant had reached MMI and had a right upper 

extremity permanent impairment rating of 25 percent.

On December 30, 2016 OWCP referred Dr. Klein’s report to Dr. David I. Krohn, a Boardcertified internist serving as a district medical adviser (DMA). In his January 27, 2016 report, the 

DMA requested additional information from Dr. Klein, including the diagnostic criteria points 

from Table 15-25 and the basis upon which he had reached his assignment of grade modifiers.

On February 10, 2017 OWCP again referred appellant to Dr. Klein for a follow up 

examination. On March 23, 2017 Dr. Klein reexamined appellant and referred to Table 15-24, 

page 453 of the A.M.A., Guides which lists the four criteria for a diagnosis of CRPS. He opined 

that appellant met these criteria as she had continuing pain which was disproportionate to the 

inciting event. Dr. Klein further found one symptom in three of the listed categories; sensory 

through hyperesthesia and allodynia, vasomotor through skin color changes and skin color 

asymmetry, and decreased ROM in the involved hand. He noted that appellant did not have 

sudomotor or edema changes. Dr. Klein also reported at least one sign in two categories including; 

sensory through allodynia to light touch, vasomotor changes through skin color changes and 

asymmetry, and motor/tropic changes through decreased range of motion and motor dysfunction 

or weakness in the intrinsic muscles. Finally, he found that there was no other diagnosis that better 

explained the signs and symptoms. Dr. Klein also found that appellant met the diagnostic criteria 

for CRPS as outlined in Table 15-25, page 453 of the A.M.A., Guides. He listed vasomotor 

changes including skin color changes, tropic changes including skin texture that was smooth and 

nonelastic, soft-tissue atrophy, and joint stiffness as well as radiographic signs through the bone 

scan consistent with CRPS. Dr. Klein a GMFH of 2 due to pain and symptoms with normal activity 

and medication.5 He found GMPE of 2 due to pain and moderate decreased ROM.

6

 Dr. Klein 

determined that as appellant’s bone scan was positive for CRPS, her GMCS was 2.7 He determined 

that appellant had a class 2 moderate impairment due to CRPS under Table 15-26, page 454 of the 

 

5 A.M.A., Guides 406, Table 15-7.

6

Id. at 408, Table 15-8.

7 A.M.A., Guides 410, Table 15-9.
4

A.M.A., Guides. Dr. Klein concluded that appellant had grade E or 25 percent impairment of the 

right upper extremity.

In a March 31, 2017 addendum, Dr. Klein repeated his determination of the grade 

modifiers and applied the A.M.A., Guides’ net adjustment formula to reach zero or a combined 20 

percent permanent impairment of the right upper extremity.

In a May 5, 2017 report, the DMA found that Dr. Klein had not responded to his prior 

requests. He determined that appellant had not met the diagnostic criteria for CRPS as Dr. Klein 

listed only three points from Table 15-25, dry skin, skin texture, and consistent bone scan when a 

minimum of four criteria were needed to qualify for a CDX of 1 under Table 15-26, page 454.

On June 12, 2017 OWCP again referred appellant for follow-up evaluation with Dr. Klein. 

In an August 1, 2017 report, Dr. Klein opined that appellant met the diagnostic criteria for CRPS 

listed in the A.M.A., Guides, Table 15-24, page 453, including disproportionate pain, one symptom 

in three of the four listed categories, as well as one sign in two or more of the categories listed in 

the A.M.A., Guides, Table 15-25, page 453, including edema, increased temperature, and 

decreased ROM. He found that there was no other diagnosis that better explained her condition. 

Dr. Klein listed appellant’s points consistent with CRPS as required in A.M.A., Guides, Table 15-

25 including edema, joint stiffness, positive bone scan, smooth nonelastic skin texture, and softtissue atrophy. He applied A.M.A., Guides, Table 15-26, page 454, and concluded that she had 

20 percent permanent impairment of the right upper extremity.

In a September 28, 2017 report, the DMA accepted Dr. Klein’s diagnosis of CRPS. 

However, he found discrepancies between Dr. Klein’s physical examinations on March 3, 2017 

and December 1, 2016. The DMA requested an additional second opinion evaluation to determine 

appellant’s permanent impairment for schedule award purposes. On January 3, 2018 OWCP 

expanded acceptance of appellant’s claim to include CRPS of the right upper extremity.

On January 15, 2018 OWCP referred appellant for a second opinion evaluation with

Dr. Michael A. Steingard, an osteopath Board-certified in orthopedic surgery. In a February 2, 

2018 report, Dr. Steingard found no evidence of vasomotor changes and normal hair pattern, but 

dorsal hyperalgesia in the index, middle, and thumb area of the right hand. He found loss of ROM 

in the digits and tenderness in the thenar aspect of the right thumb. Dr. Steingard reported positive 

Froment’s sign and decreased motor strength on the right. He found edema in the right hand and 

that appellant’s right hand was cooler than the left. Dr. Steingard noted that appellant’s positive 

objective findings included the bone scan. He diagnosed CRPS, RSD, and that she had initially 

sustained an open wound with infection. Dr. Steingard determined that appellant had CRPS I 

based on sensory hyperesthesia, edema, and hyperalgesia in accordance with Table 15-24 page 

453 of the A.M.A., Guides. He also found under Table 15-25, page 453, appellant had edema, 

dystrophic changes of soft tissue atrophy at the tips of her fingers, joint stiffness, and positive bone 

scan. Dr. Steingard determined that in accordance with Table 15-26 page 454 of the A.M.A., 

Guides appellant had mild class 1 CRPS of only four points with default grade C of seven percent 

permanent impairment. He found moderate problems on physical examination as appellant had a 

lack of grip or grade 2, he found a GMCS of 1. After applying the net adjustment formula,

Dr. Steingard opined appellant had 13 percent permanent impairment rating of the right upper 

extremity due to CRPS. He listed the date of MMI as February 12, 2014. Dr. Steingard noted that 
5

he did not use range of motion rating because appellant had full ROM although she reported 

stiffness.

In a July 18, 2018 report, the DMA agreed with Dr. Steingard’s application of the A.M.A., 

Guides and determined that appellant had 13 percent permanent impairment of the right upper 

extremity. He found that as Dr. Frankel had suggested further treatment, appellant was not at MMI 

by the date of Dr. Frankel’s last examination. The DMA further noted that there were differences 

between Dr. Klein’s findings on physical examination and those of Dr. Steingard indicating 

ongoing improvement. He determined that the date of MMI was February 2, 2018, the date of

Dr. Steingard’s report as by that point no further improvement was likely from either additional 

medical or surgical treatment. 

By decision dated July 27, 2018, OWCP granted appellant a schedule award for 13 percent 

permanent impairment of the right upper extremity. It found February 2, 2018 was the date of 

MMI and found that the period of the award was for 40.56 weeks, from February 2 through 

November 12, 2018. 

LEGAL PRECEDENT

The schedule award provision of FECA8and its implementing regulations set forth the 

number of weeks of compensation payable to employees sustaining permanent impairment from 

loss or loss of use, of scheduled members or functions of the body. FECA, however, does not 

specify the manner in which the percentage of loss of a member shall be determined. The method 

used in making such determination is a matter which rests in the sound discretion of OWCP. For 

consistent results and to ensure equal justice, the Board has authorized the use of a single set of 

tables so that there may be uniform standards applicable to all claimants. The A.M.A., Guides has 

been adopted by OWCP as a standard for evaluation of schedule losses and the Board has 

concurred in such adoption.9 For schedule awards after May 1, 2009, the impairment is evaluated 

under the sixth edition of the A.M.A., Guides, published in 2009.10

The sixth edition of the A.M.A., Guides provides a diagnosis-based method of evaluation 

utilizing the World Health Organization’s International Classification of Functioning, Disability 

and Health (ICF).11 In addressing impairment for the upper extremities, the sixth edition of the 

A.M.A., Guides requires identifying the impairment class for the diagnosed condition, which is 

 

8 5 U.S.C. § 8107.

9 20 C.F.R. § 10.404 (1999); D.S., Docket No. 19-0292 (issued June 21, 2019); Jacqueline S. Harris, 54 ECAB 

139 (2002).

10 Federal (FECA) Procedure Manual, Part 2 -- Claims, Schedule Awards and Permanent Disability Claims, Chapter 

2.808.5a (March 2017); Federal (FECA) Procedure Manual, Part 3 -- Medical, Schedule Awards, Chapter 3.700.2 and 

Exhibit 1 (January 2010).

11 A.M.A., Guides 3, section 1.3, The International Classification of Functioning, Disability and Health (ICF): A 

Contemporary Model of Disablement (6th ed. 2009).
6

then adjusted by GMFH, GMPE, and GMCS.12 Evaluators are directed to provide rationale for 

their impairment rating choices, including the choices of diagnosis from regional grids and 

calculations of modifier scores.13

Impairment due to CRPS is evaluated under the scheme found in Table 15-26 (Complex 

Regional Pain syndrome (UEI)) as well as Table 15-24 and Table 15-25 and the accompanying 

relevant text.14 The grade modifier level (ranging from zero to four) are described from the 

categories of functional history, clinical studies, and physical examination. The grade modifier 

levels are averaged to arrive at the appropriate overall grade modifier level and to identify a class 

rating value. If that class number is not supported by the objective diagnostic criteria point, the 

highest class specified by those points is selected.15 The rating for CRPS is a “stand alone”

approach.16

ANALYSIS

The Board finds that appellant has not met her burden of proof to establish greater than 13 

percent permanent impairment of the right upper extremity, for which she previously received a 

schedule award.

OWCP referred appellant for second opinion evaluations with Drs. Klein and Steingard. 

In accordance with its procedures, it properly referred the reports of these physicians to its DMA,

Dr. Krohn, who determined that Dr. Klein properly confirmed appellant’s diagnosis of CRPS, but 

that his reports provided conflicting physical findings and inconsistent correlation with the 

A.M.A., Guides. Dr. Klein initially reported that appellant had no vasomotor changes, but later, 

on March 23, 2017, he found vasomotor changes as well as providing varying evaluations of 

appellant’s skin changes and soft tissue atrophy. His evaluation of appellant’s permanent 

impairment also varied and was inconsistent with A.M.A., Guides. The Board therefore finds that 

Dr. Klein’s reports lack probative value and are insufficient to establish appellant’s permanent 

impairment for schedule award purposes.17 

The Board finds that the DMA properly requested an additional second opinion evaluation. 

The DMA reviewed Dr. Steingard’s February 2, 2018 report and determined that it provided 

sufficient findings and a correct application of the A.M.A., Guides. He determined that appellant’s 

date of MMI was February 2, 2018, the date of Dr. Steingard’s report, as by that point no further 

 

12 A.M.A., Guides 385-419; see M.P., Docket No. 13-2087 (issued April 8, 2014).

13 D.S., supra note 8; R.V., Docket No. 10-1827 (issued April 1, 2011).

14 A.M.A., Guides 450-54.

15 A.M.A., Guides 452. The A.M.A., Guides provided that if an individual has grade modifiers that ultimately 

resulted in assignment to class 2 but the objective diagnostic criteria points were only four, the individual would be 

assigned to class 1, and the physician may muse clinical judgment to decrease or increase the grade within the assigned 

class and must explain in detail the rationale for any adjustments.

16 Id.

17 E.A., Docket No. 14-0834 (issued September 16, 2014).
7

improvement was likely. The DMA explained that Dr. Frankel had suggested further treatment, 

and that there were differences between Dr. Klein’s findings on physical examination and those of

Dr. Steingard. Dr. Krohn found that appellant had 13 percent impairment of the right upper 

extremity due to CRPS.

The Board finds that the DMA described how he arrived at his conclusion by listing 

appropriate tables and pages in the A.M.A., Guides, establishing that appellant sustained 13 

percent permanent impairment of the right upper extremity. The DMA’s opinion represents the 

weight of the medical evidence and establishes that appellant does not have greater than 13 percent 

permanent impairment of each upper extremity previously awarded. Thus, the Board finds 

appellant has not met her burden of proof to establish that she is entitled to an additional schedule 

award. 

The Board further finds that there is no current medical evidence of record, in conformance 

with the sixth edition of the A.M.A., Guides, establishing that appellant has more than 13 percent 

permanent impairment of the right upper extremity. Accordingly, appellant has not established 

entitlement to a schedule award greater than that previously awarded.

Appellant may request a schedule award or increased schedule award at any time based on 

evidence of a new exposure or medical evidence showing progression of an employment-related 

condition resulting in permanent impairment or increased impairment. 

CONCLUSION

The Board finds that appellant has not met her burden of proof to establish greater than 13 

percent permanent impairment of the right upper extremity, for which she previously received a 

schedule award.
8

ORDER

IT IS HEREBY ORDERED THAT the July 27, 2018 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: September 16, 2019

Washington, DC

Christopher J. Godfrey, Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Alec J. Koromilas, Alternate Judge

Employees’ Compensation Appeals Board