United States Department of Labor

Employees’ Compensation Appeals Board

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E.B., Appellant

and

DEPARTMENT OF THE NAVY, NAVAL 

STATION GREAT LAKES, Great Lakes, IL, 

Employer

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Docket No. 18-0014

Issued: July 12, 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 October 2, 2017 appellant filed a timely appeal from a September 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 this case.

ISSUE

The issue is whether appellant has met his burden of proof to establish a traumatic injury

causally related to the accepted August 6, 2017 employment incident.

FACTUAL HISTORY

On August 9, 2017 appellant, then a 40-year-old firefighter, filed a traumatic injury claim 

(Form CA-1) alleging that at noon on August 6, 2017, he felt muscle tightness and soreness in his 

 

1 5 U.S.C. § 8101 et seq.
2

mid-back area after unloading and reloading firefighting equipment from one vehicle to another. 

On the reverse side of the claim form, appellant’s supervisor noted that there were inconsistencies 

in appellant’s description of what occurred, and that there was no medical evidence to support 

continuation of pay.

In an e-mail dated August 9, 2017, another supervisor advised that he had spoken to a 

coworker regarding appellant’s claim. The coworker indicated that appellant had mentioned to 

him on the following Monday that his back was stiff, and that he thought he had slept on it wrong.

By development letter dated August 16, 2017, OWCP advised appellant that the evidence 

of record was insufficient to establish his claim. It noted that it had not received any medical 

evidence in support of his claim. OWCP also requested additional factual information regarding 

the alleged injury. It afforded appellant 30 days to submit the requested information and medical 

evidence.

In a narrative statement dated September 1, 2017, appellant recalled that, on August 6, 

2017, his supervisor directed him and his crew to unload their fire engine of all its equipment, 

which required removing pieces of heavy equipment from the vehicle and placing them on the 

ground; an activity involving lifting, twisting, and turning. Shortly after completing the task, 

appellant’s mid-back began to tighten up, and he began experiencing pain and soreness. By that 

evening, the pain had increased considerably, and appellant notified his supervisor he might fill 

out a Form CA-1 if his back pain did not subside. That night, while sleeping, appellant kept 

awakening due to the pain and stiffness. The next morning, August 7, 2017, his back felt slightly

better after he got up and moved around. However, through the course of that day’s work shift, 

his back began to worsen again. That night appellant slept in a different bed than his own, and he 

awoke multiple times in pain. The following morning, August 8, 2017, he was in severe pain and 

was unable to move or sit properly without experiencing back pain. Appellant notified the onduty shift supervisor that his pain had not subsided, but rather had gotten a lot worse and that he 

was unable to finish his shift. Appellant then completed a Form CA-1 and left to see his physician. 

He explained that, from the time of the injury until he left, he remained on duty the entire time. 

During that period appellant went on multiple emergencies while wearing full personal protective 

equipment (PPE) weighing 70 pounds. Appellant also stated that he slept in different beds, both 

of which contributed to the pain and tightness in his back. He noted that he had not sustained any 

other injury or disability during this time or before the August 6, 2017 employment incident.

In a report dated August 8, 2017, Dr. Syeda Farheen Ali, an internist, assessed appellant 

with upper back pain. She noted that on August 6, 2017, appellant felt his mid-back tighten up, 

and that when he awoke, he could barely move. Appellant noted that he did not recall injuring it, 

but that earlier in the day he was loading trucks with heavy equipment. Dr. Ali reported that he 

did feel a back spasm at that time, but did not pay attention to it. She noted tenderness and spasm 

of the thoracic back on examination.

In an August 23, 2017 attending physician’s report (Form CA-20), Dr. Ali assessed

appellant with spasm of the upper (thoracic) back and opined that his condition was caused by 

unloading trucks while on duty. She indicated that he was totally disabled from work for the period 

August 8 through 15, 2017, but could resume regular work effective August 16, 2017. In an 
3

August 23, 2017 work capacity evaluation (Form OWCP-5c), Dr. Ali noted that appellant was 

capable of performing his usual job without restrictions.

By decision dated September 20, 2017, OWCP denied appellant’s claim. It found that 

although the evidence of record established that the employment incident occurred as alleged, it 

was insufficient to establish a diagnosed medical condition. OWCP explained that “pain” was a 

symptom, not a diagnosis. 

LEGAL PRECEDENT

An employee seeking benefits under FECA2 has the burden of proof to establish the 

essential elements of his or her claim by the weight of the reliable, probative, and substantial 

evidence, including that an injury was sustained in the performance of duty as alleged, and that 

any specific condition or disability claimed is causally related to the employment injury.3

To determine if an employee sustained a traumatic injury in the performance of duty, 

OWCP begins with an analysis of whether fact of injury has been established. Generally, fact of 

injury consists of two components that must be considered in conjunction with one another. The 

first component is whether the employee actually experienced the employment incident that 

allegedly occurred.4 The second component is whether the employment incident caused a personal 

injury.5 An employee may establish that an injury occurred in the performance of duty as alleged, 

but fail to establish that the disability or specific condition for which compensation is being 

claimed is causally related to the injury.6

Causal relationship is a medical issue and the medical evidence generally required to 

establish causal relationship is rationalized medical opinion evidence.7 Rationalized medical 

opinion evidence is medical evidence which includes a physician’s rationalized opinion on 

whether there is causal relationship between the employee’s diagnosed condition and the 

compensable employment factors.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 

 

2

Id.

3 20 C.F.R. § 10.115(e), (f); J.O., Docket No. 18-0057 (issued May 29, 2018); see Jacquelyn L. Oliver, 48 ECAB 

232, 235-36 (1996).

4 See J.O., id.; Elaine Pendleton, 40 ECAB 1143 (1989).

5 See J.O., id.; John J. Carlone, 41 ECAB 354 (1989). 

6 See J.O., id.; Shirley A. Temple, 48 ECAB 404, 407 (1997).

7 Y.J., Docket No. 08-1167 (issued October 7, 2008); A.D., 58 ECAB 149 (2006); D’Wayne Avila, 57 ECAB 

642 (2006).

8

J.J., Docket No. 09-27 (issued February 10, 2009); Michael S. Mina, 57 ECAB 379 (2006)
4

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 

ANALYSIS

Appellant claimed to have injured his mid-back on August 6, 2017 while unloading and 

reloading fire equipment from one vehicle to another in the performance of duty. By decision 

dated September 20, 2017, OWCP denied his traumatic injury claim, finding that he had not 

submitted evidence of a diagnosed medical condition in connection with the August 6, 2017 

employment incident.

The Board finds that appellant has not submitted medical evidence from a physician 

containing a medical diagnosis in connection with the August 6, 2017 employment incident.10 

Appellant submitted reports from Dr. Ali dated August 8 and 23, 2017, containing assessments of 

upper back pain and spasm of the upper back, respectively.

The Board has held that pain and spasm are descriptions of symptoms and are not, in 

themselves, considered firm medical diagnoses.11 Dr. Ali’s descriptions of appellant’s upper back 

pain and spasm are, therefore, insufficient to establish a firm medical diagnosis in connection with 

the accepted employment incident.12 As such, the Board finds that appellant has not submitted 

sufficient medical evidence to establish his claim for compensation.

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 his burden of proof to establish a traumatic

injury causally related to the accepted August 6, 2017 employment incident.

 

9

I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989).

10 See L.F., Docket No. 17-1511 (issued November 28, 2017); J.P., Docket No. 14-0087 (issued March 14, 2014).

11 See B.P., Docket No. 12-1345 (issued November 13, 2012) (regarding pain); C.F., Docket No. 08-1102 (issued 

October 10, 2008) (regarding pain); J.S., Docket No. 07-0881 (issued August 1, 2007) (regarding spasm).

12 Findings of pain or discomfort alone do not satisfy the medical aspect of the fact of injury medical determination. 

Federal (FECA) Procedure Manual, Part 2 -- Claims, Fact of Injury, Chapter 2.803.4a(6) (August 2012).
5

ORDER

IT IS HEREBY ORDERED THAT the September 20, 2017 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: July 12, 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