United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

A.W., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

OVERTON BROOKS VA MEDICAL CENTER, 

Shreveport, LA, Employer

__________________________________________

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Docket No. 19-1857

Issued: May 5, 2020

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Deputy Chief Judge

JANICE B. ASKIN, Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On September 8, 2019 appellant filed a timely appeal from a July 5, 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 bilateral carpal 

tunnel syndrome causally related to the accepted April 3, 2017 employment injury.

FACTUAL HISTORY

On April 4, 2017 appellant, then a 37-year-old nurse, filed a traumatic injury claim (Form 

CA-1) alleging that on April 3, 2017 she injured her wrist, back, arms, and neck as she was 

performing compressions on a mannequin while in the performance of duty. On the reverse side 

 

1 5 U.S.C. § 8101 et seq.
2

of the claim form, her supervisor indicated that appellant’s injury was caused by her own 

misconduct as she was using her backside to perform compressions on the mannequin. Appellant 

did not stop work. 

In a development letter dated May 18, 2017, OWCP advised appellant of the factual and 

medical deficiencies of her claim. It informed her of the type of evidence necessary to establish 

her claim and provided a questionnaire for her completion regarding the circumstances of the 

injury. OWCP also requested a narrative medical report from appellant’s treating physician which 

contained a detailed description of findings and diagnoses, explaining how the alleged incident 

caused, contributed to, or aggravated her medical conditions. It afforded her 30 days to submit the 

necessary evidence. 

In response, appellant provided an April 3, 2017 statement from A.M., a registered nurse, 

who reported that she observed appellant sitting on top of a mannequin in order to perform 

compressions on it. A.M. told appellant that her technique was inappropriate and appellant 

explained to A.M. that she was unable to do the compressions with her arms because she was 

weak, had no strength, and was exhausted. 

In an April 4, 2017 witness statement, J.D., a nursing staff development instructor,

observed appellant having difficulty performing compressions on a voice-activated mannequin and 

that she was previously observed performing the compressions with her backside. After observing 

that appellant could not perform proper compressions on a cushion or on the floor after 

approximately 30 attempts, J.D. demonstrated the proper technique and allowed appellant to 

attempt the compressions again. Appellant informed J.D. that she was tired and that her wrists 

hurt. J.D. then informed appellant that she may need to get a waiver from her physician if she was 

having a physical issue. 

In an e-mail of even date, Dr. Robert Lukeman, Board-certified in internal medicine, 

contacted appellant’s supervisor and reported that he observed appellant performing compressions 

on a mannequin by repeatedly sitting on its chest, lifting up, and sitting down again. He 

immediately asked A.M. to address the technique with appellant. 

In an April 4, 2017 incident report, N.B., appellant’s supervisor, provided that appellant 

verbalized that she was unable to complete her compressions on a mannequin despite several 

attempts. Appellant was observed by another employee using her backside to perform the 

compressions on the mannequin. An education instructor attempted to assist appellant with her 

compressions, however, appellant was still unable to complete her training. 

In a partially legible April 4, 2017 medical report, Dr. Sudarshan Tanga, Board-certified in 

pain medicine, recorded that appellant experienced pain in her arms, shoulders, back, and wrists 

while performing compressions on a mannequin at work. Appellant indicated that, because she 

was small, it was difficult for her to perform the compressions and that she was instructed to 

continue her compressions after she informed her instructor that she was experiencing pain. 

Dr. Tanga diagnosed sprains of her shoulders, back, and upper extremities and advised that she 

take an over-the-counter medication to treat her injuries. In a medical note of even date, he noted 

pain in appellant’s shoulders, back, and wrists and recommended work restrictions until her next 

appointment on April 10, 2017. 
3

In April 4, 2017 progress notes, Ramona Grant and Rachal Carter, registered nurses, and 

Helen Hall, a physician assistant, described appellant’s injuries as a flare-up of her fibromyalgia, 

severe generalized pain, and musculoskeletal pain. Ms. Hall reported that appellant presented with 

a “fibromyalgia crisis” after attempting to perform repeated compressions on a mannequin. 

In an April 10, 2017 medical note, Dr. Tanga noted pain in appellant’s right arm and 

recommended additional work restrictions until she could be seen by an orthopedic physician. 

In an April 17, 2017 medical report, Dr. Michael Acurio, a Board-certified orthopedic 

surgeon, reported that appellant experienced pain in her wrists, arms, neck, and shoulders as a 

result of repeatedly performing compressions on a mannequin. He also noted her history of 

fibromyalgia and that she was informed in an emergency room that her pain was due to a flare-up 

of her condition. Upon evaluation and review of x-rays of appellant’s cervical spine and bilateral 

shoulders, Dr. Acurio diagnosed carpal tunnel syndrome and a cervical strain. In a medical note 

of even date, he explained that she would need to remain out of work until her next appointment 

where further recommendations could be made. 

In an April 24, 2017 electromyography and nerve conduction velocities report, Dr. David 

Adams, a Board-certified neurologist, saw appellant due to the onset of numbness and tingling in 

both of her hands after performing compressions on a mannequin on April 3, 2017. He found 

bilateral carpal tunnel syndrome, but no evidence of radiculopathy, brachial plexopathy, or ulnar 

neuropathy in either upper extremity. 

In a medical report of even date, Dr. Acurio recorded appellant’s complaints of upper 

extremity numbness and tingling. Based on her diagnostic studies and evaluation, he diagnosed 

bilateral carpal tunnel syndrome, a cervical strain, and cervical radiculopathy. Dr. Acurio opined 

that appellant would need a carpal tunnel release to treat her condition. In an April 24, 2017 

medical note, he informed the employing establishment that she was in the process of scheduling 

a magnetic resonance imaging (MRI) scan and would need to remain out of work until further 

notice. 

In an April 27, 2017 diagnostic report, Dr. Kurt Grozinger performed an MRI scan of 

appellant’s cervical spine due to her history of right arm pain and numbness. He found an 

impression of a small central disc bulge at C5-6 and reported that her MRI scan was otherwise 

normal. 

In a May 22, 2017 medical report, Dr. Acurio noted appellant’s complaints of numbness 

and tingling in her hands, as well as pain in her neck and back. Upon consultation with her, he 

scheduled a carpal tunnel release procedure for May 26, 2017 to treat her condition. In a medical 

note of even date, Dr. Acurio informed the employing establishment that appellant would need 

nine weeks off from work following the procedure. 

In a June 5, 2017 medical report, Dr. Acurio updated appellant’s condition after her 

May 26, 2017 right carpal tunnel release and scheduled her left carpal tunnel release for 

June 23, 2017. 

In response to OWCP’s questionnaire, appellant, through counsel, submitted a June 13, 

2017 statement in which she described the April 3, 2017 employment incident. Appellant asserted 

that she used all of the strength in her arms, hands, and upper body to perform compressions, but 
4

the compressions were not registered by the mannequin. Sometime after her instructor moved the 

mannequin to the ground to assist her, she began to experience pain in her wrists, neck, arms, and 

shoulders with numbness and tingling going into her hands. The next day, appellant sought care 

from the emergency department and eventually from Dr. Acurio as her pain continued. She also 

noted that she had been diagnosed with fibromyalgia in October 2016 and that she had previously 

experienced neck and back pain that came and went prior to the April 3, 2017 employment 

incident. 

By decision dated June 19, 2017, OWCP denied appellant’s traumatic injury claim finding 

that the evidence of record was insufficient to establish that the injury and/or events occurred as 

she described. It explained that the circumstances of her injury were not consistent and therefore 

failed to support that her injury occurred in the manner she alleged. OWCP concluded, therefore, 

that the requirements had not been met to establish an injury as defined by FECA. 

OWCP continued to receive evidence. In a June 20, 2017 medical note, Dr. Acurio noted 

that appellant suffered an injury while performing cardiopulmonary resuscitation (CPR) and that 

he believed that this worsened her carpal tunnel syndrome due to the repetitive compressions. 

In a July 18, 2017 letter, the employing establishment controverted appellant’s claim. It 

argued that the evidence of record failed to establish fact of injury and causal relationship. 

In a July 31, 2017 medical report, Dr. Acurio updated appellant’s condition and advised 

that she attend physical therapy and remain off work for a month until her next appointment. 

In an August 28, 2017 medical report, Dr. Acurio noted that appellant was experiencing 

some popping in her left hand, but therapy had helped her conditions. He recommended that she

continue her therapy sessions and remain off work. 

On December 13, 2017 appellant, through counsel, requested reconsideration. Counsel

explained that appellant performed several rounds of CPR using her arms, hands, and upper body 

strength and experienced increased pain in her wrists, neck, arms, and shoulders, as well as 

numbness and tingling in her hands. He asserted that the totality of the evidence was sufficient to 

establish her claim. 

In a September 25, 2017 narrative medical report, Dr. Acurio discussed the nature of 

appellant’s carpal tunnel syndrome. He explained that repetitive motions, such as performing 

CPR, and extension of the wrists, can cause swelling and inflammation in the carpal canal, putting 

pressure on the median nerve. Dr. Acurio opined that the chest compressions appellant performed 

on the mannequin had increased the swelling and pressure on her median nerve which 

subsequently resulted in her carpal tunnel syndrome. He concluded that the April 3, 2017 

employment incident had both caused and exacerbated her carpal tunnel syndrome. 

In an October 23, 2017 medical report, Dr. Acurio diagnosed bilateral carpal tunnel 

syndrome and early chronic regional pain syndrome in appellant’s left upper extremity. 

In a November 27, 2017 medical note, Dr. Acurio recommended that appellant remain off

work until her next appointment on December 26, 2017. 
5

In a January 26, 2018 letter, the employing establish again controverted appellant’s claim 

arguing that the evidence of record failed to establish fact of injury and causal relationship. 

On March 1, 2018 OWCP referred appellant to Dr. Robert Holladay IV, a Board-certified 

orthopedic surgeon, for a second opinion evaluation to determine the nature and extent of her 

employment-related conditions. 

In his April 3, 2018 report, Dr. Holladay reviewed the statement of accepted facts (SOAF), 

history of injury, and the medical evidence of record. He conducted a physical examination and

found that appellant had full range of motion of all areas with some complaints of discomfort with 

certain movements. Dr. Holladay did not find objective evidence of swelling, deformity, 

neurological loss, or motor loss. On clinical examination of appellant’s lower back, he found no 

objective evidence of an acute structural problem associated with the lumbar spine complaints. 

Dr. Holladay explained that, at most, he could associate the April 3, 2017 mechanism of injury to 

a temporary soft tissue strain/sprain of the wrists and a strain/sprain of the scapula and upper 

thoracic spine posteriorly. He opined that the one-time incident on April 3, 2017 would not be 

consistent with known medical literature regarding the cause of carpal tunnel syndrome and that it 

was most likely a preexisting condition. Dr. Holladay discussed that the “American Medical 

Association, Guides to the Evaluation of Disease and Injury Causation” provide that the activity 

of CPR would not meet the criteria of force, repetition, and posture necessary to have a causal 

association. He also asserted that the objective evidence in the medical record did not support the 

concept of an aggravation or acceleration of appellant’s preexisting bilateral carpal tunnel 

syndrome. Dr. Holladay concluded that she sustained a soft tissue sprain/strain in both wrists and 

the upper thoracic spine and scapular area that have long since resolved. 

By decision dated April 18, 2018, OWCP affirmed in part and modified in part the June 19, 

2017 decision. It accepted and closed appellant’s traumatic injury claim for a strain of other 

muscles, facias, and tendons at the shoulder and upper arm level in the right and left arms, sprains 

of the right and left wrists, and a sprain of the ligaments of the thoracic spine. OWCP also 

determined, however, that the evidence of record did not support that her bilateral carpal tunnel 

syndrome was causally related to the April 3, 2017 employment injury. 

OWCP continued to receive evidence. In a September 18, 2018 medical report, Dr. Acurio 

disagreed with Dr. Holladay’s report, explaining that the chest compressions appellant performed 

on the mannequin increased the swelling and pressure on the median nerve and subsequently 

resulted in carpal tunnel syndrome. He opined that the April 3, 2017 employment incident caused 

and certainly exacerbated her carpal tunnel syndrome. With regard to Dr. Holladay’s report,

Dr. Acurio noted that appellant had symptoms prior to the April 3, 2017 employment injury and 

that she had more symptoms afterwards, meaning the injury was an exacerbation of a preexisting 

condition. 

In November 12 and December 8, 2018 medical reports, Dr. Jeffrey Fritz, Board-certified 

in internal medicine, noted that appellant noted pain in her neck, back, and bilateral wrists due to 

a work incident in which she was performing compressions on a mannequin repeatedly. He 

diagnosed sprains of her wrists and hands, the thoracic spine, and her upper arms. 

On April 11, 2019 appellant, through counsel, requested reconsideration of OWCP’s 

April 18, 2018 decision. 
6

Appellant attached a March 27, 2019 medical report, in which Dr. Fritz opined that, per his 

review of her medical history, evaluation, and surrounding circumstances, the April 3, 20172

employment incident exacerbated her preexisting bilateral carpal tunnel syndrome. Dr. Fitz

disagreed with Dr. Holladay’s conclusion that her conditions were preexisting and therefore were 

not caused by her April 3, 2017 work injury. He further explained that carpal tunnel is caused by 

pressure on the median nerve in the carpal canal and that in a person with preexisting carpal tunnel, 

repetitive motions of the wrists in a short period of time can increase swelling and inflammation, 

putting more pressure on the median nerve and exacerbating the condition. Dr. Fritz opined that 

performing CPR on the mannequin required repetitive motions and extension of the wrists which

increased the swelling and pressure on appellant’s median nerves and thus exacerbated her bilateral 

carpal tunnel syndrome. 

By decision dated July 5, 2019, OWCP affirmed its previous decision finding that the new 

medical evidence was of insufficient probative value to establish that appellant’s preexisting 

condition of carpal tunnel was temporarily or permanently aggravated as a result of her accepted 

April 3, 2017 employment injury. 

LEGAL PRECEDENT

When 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.3 To establish causal relationship between the condition, as well 

as any attendant disability claimed and the employment event or incident, the employee must 

submit rationalized medical opinion evidence sufficient to establish such causal relationship.4 The 

opinion of the physician must be based on a complete factual and medical background, 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 claimant.5 

In a case where a preexisting condition involving the same part of the body is present and 

the issue of causal relationship therefore involves aggravation, acceleration, or precipitation, the 

physician must provide a rationalized medical opinion that differentiates between the effects of the 

work-related injury or disease and the preexisting condition.6

Section 8123(a) of FECA provides that, if there is disagreement between the physician 

making the examination for the United States and the physician of the employee, the Secretary 

 

2 The Board notes that Dr. Fritz’ report includes that the date of the employment injury was April 3, 2018, but this 

appears to be a typographical error as the date of the accepted employment injury was April 3, 2017.

3

J.G., Docket No. 19-1303 (issued February 6, 2020); F.L., Docket No. 17-1613 (issued August 15, 2018).

4 K.V., Docket No. 18-0723 (issued November 9, 2018).

5

I.J., 59 ECAB 408 (2008).

6 Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3e (January 2013); N.C., 

Docket No. 19-1191 (issued December 19, 2019); R.D., Docket No. 18-1551 (issued March 1, 2019).
7

shall appoint a third physician who shall make an examination.7 The implementing regulations 

state that, if a conflict exists between the medical opinion of the employee’s physician and the 

medical opinion of either a second opinion physician or a DMA, OWCP shall appoint a third 

physician to make an examination.8 When there exist opposing medical reports of virtually equal 

weight and rationale and the case is referred to an impartial medical specialist for the purpose of

resolving the conflict, the opinion of such specialist, if sufficiently well rationalized and based 

upon a proper factual background, must be given special weight.9

ANALYSIS

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

In his April 3, 2018 medical report, Dr. Holladay opined that the one-time incident on 

April 3, 2017 would not be consistent with known medical literature regarding the cause of carpal 

tunnel syndrome and that it was most likely a preexisting condition. He noted that the “A.M.A.,

Guides on Disease and Injury Causation” provide that the activity of CPR would not meet the 

criteria of force, repetition, and posture necessary to have a causal association. Dr. Holladay also 

asserted that the objective evidence in the medical record did not support the concept of an 

aggravation or acceleration of appellant’s preexisting bilateral carpal tunnel syndrome. He 

summarized by stating that she sustained a soft tissue sprain/strain in both wrists and the upper 

thoracic spine and scapular area that have long since resolved. 

In his September 25, 2017 and September 18, 2018 medical reports, Dr. Acurio explained 

that repetitive motions, such as performing CPR and extension of the wrists, can cause swelling 

and inflammation in the carpal canal, putting pressure on the median nerve. He disagreed with

Dr. Holladay’s findings, asserting that the April 3, 2017 employment incident exacerbated 

appellant’s preexisting bilateral carpal tunnel syndrome. Further, in his March 27, 2019 medical 

report, Dr. Fritz explained that in a person with preexisting carpal tunnel, repetitive motions of the 

wrists in a short period of time can increase swelling and inflammation, putting more pressure on 

the median nerve and exacerbating the condition. Both Drs. Acurio and Fritz opined that the 

repetitive motions and extension of the wrists involved in performing CPR on the mannequin 

increased the swelling and pressure on appellant’s median nerves and thus exacerbated her 

preexisting bilateral carpal tunnel syndrome.

The Board finds that a conflict in medical opinion has been created between appellant’s 

attending physicians and that of the second opinion physician regarding whether her preexisting 

bilateral carpal tunnel syndrome was aggravated by the accepted April 3, 2017 employment 

injury.

10

 Section 8123 of FECA provides that, if there is a disagreement between the physician 

 

7 5 U.S.C. § 8123(a); see Y.A., 59 ECAB 701 (2008).

8 20 C.F.R. § 10.321.

9 K.S., Docket No. 19-0082 (issued July 29, 2019); V.G., 59 ECAB 635 (2008).

10 See S.M., Docket No. 19-0397 (issued August 7, 2019).
8

making the examination for the United States and the employee’s physician, OWCP shall appoint 

a third physician who shall make an examination.11

As there remains an unresolved conflict in medical opinion regarding whether appellant’s 

diagnosed bilateral carpal tunnel syndrome condition is causally related to, or a consequence of, 

the accepted April 3, 2017 employment injury the case shall be remanded to OWCP for creation 

of an updated SOAF and referral to an appropriate specialist to obtain an impartial medical opinion 

regarding whether the acceptance of her claim should be expanded to include his diagnosed 

bilateral carpal tunnel syndrome condition. Following this and any other development deemed 

necessary, OWCP shall issue a de novo decision.

CONCLUSION

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

ORDER

IT IS HEREBY ORDERED THAT the July 8, 2019 decision of the Office of Workers’

Compensation Programs is set aside and the case is remanded for further proceedings consistent 

with this decision of the Board.

Issued: May 5, 2020

Washington, DC

Christopher J. Godfrey, Deputy Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board

 

11 Supra note 7.