United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

S.L., Appellant

and

U.S. POSTAL SERVICE, GREENSBORO 

PROCESSING & DISTRIBUTION CENTER, 

Greensboro, NC, Employer

__________________________________________

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Docket No. 21-0128

Issued: June 4, 2021

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

JANICE B. ASKIN, Judge

PATRICIA H. FITZGERALD, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On November 2, 2020 appellant filed a timely appeal from a June 22, 2020 merit decision 

of the Office of Workers’ Compensation Programs (OWCP).1 Pursuant to the Federal Employees’

 

1 Appellant submitted a timely request for oral argument before the Board. 20 C.F.R. § 501.5(b). Pursuant to the 

Board’s Rules of Procedure, oral argument may be held in the discretion of the Board. 20 C.F.R. § 501.5(a). In 

support of her oral argument request, appellant asserted that oral argument should be granted because she sustained 

an injury from the accepted November 15, 2019 employment incident, which placed her on light-duty work to the 

present day. The Board, in exercising its discretion, denies appellant’s request for oral argument because this matter 

requires an evaluation of the medical evidence presented. As such, the arguments on appeal can adequately be 

addressed in a decision based on a review of the case record. Oral argument in this appeal would further delay issuance 

of a Board decision and not serve a useful purpose. As such, the oral argument request is denied and this decision is 

based on the case record as submitted to the Board.
2

Compensation Act2(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over 

the merits of this case.3

ISSUE

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

condition causally related to the accepted November 15, 2019 employment incident.

FACTUAL HISTORY

On November 21, 2019 appellant, then a 26-year-old mail handler, filed a traumatic injury 

claim (Form CA-1) alleging that on November 15, 2019 she strained the middle of her back when 

she felt pain in her upper shoulder while inducting mail in the performance of duty. She stopped 

work on November 15, 2019.

A November 15, 2019 after-visit summary report indicated that appellant presented to the 

emergency department with complaints of back pain. Dr. Stephen Rancour, Board-certified in 

emergency medicine, diagnosed back spasm. In a note of even date, her provided work restrictions 

and indicated that appellant could return to work on November 17, 2019.

In a November 22, 2019 attending physician’s report, Part B of an authorization for 

medical examination and/or treatment (Form CA-16), Dr. Shannon R. Banks, Board-certified in 

family practice, indicated that appellant had preexisting upper back pain, diagnosed back muscle 

spasm, and checked a box marked “Yes,” indicating that the condition was caused or aggravated 

by the described employment activity. In a duty status report (Form CA-17) of even date, she

noted that appellant experienced back muscle spasms and tenderness in trapezius/thoracic spine. 

Dr. Banks diagnosed back spasm and provided work restrictions. In a note of even date, she

indicated that appellant could return to light-duty work with restrictions on December 2, 2019.

In a December 2, 2019 development letter, OWCP requested that appellant submit 

additional evidence in support of her claim, including a qualified physician’s opinion, which 

established that the reported November 15, 2019 employment incident caused, aggravated, or 

precipitated a diagnosed medical condition. It afforded her 30 days to submit the requested 

medical evidence.

OWCP received a November 15, 2019 medical report by Dr. Rancour who noted that 

appellant presented with upper back pain, which occurred at work earlier that day when she was 

lifting a box of mail above her head. Dr. Rancour indicated that appellant did not experience pain 

prior to lifting the box. He reported that she felt no associated numbness, tingling, or weakness. 

 

2 5 U.S.C. § 8101 et seq.

3 The Board notes that appellant submitted additional evidence on appeal. 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.
3

Dr. Rancour conducted a physical examination, which demonstrated arthralgias, back pain, and 

myalgias. He diagnosed back spasm.

In a November 15, 2019 medical report, Dr. Banks noted that appellant was seen that day 

for a work-related injury. She indicated that appellant experienced a burning pain in her upper 

back at work while moving trays of mail above her head. Dr. Banks indicated that she experienced 

back pain since starting her job. She conducted a physical examination and diagnosed back spasm. 

An after visit summary of even date also indicated that appellant was seen by Dr. Banks for back 

spasm. In a note of even date, Dr. Banks excused appellant from work for the period November 15 

through 22, 2019.

In a November 22, 2019 medical report, Dr. Banks again diagnosed back spasm. In a 

December 16, 2019 medical report, she noted that appellant experienced a burning sensation in 

her upper back after getting off work each day. Dr. Banks diagnosed muscle spasm and 

recommended that appellant should continue working with restrictions. In a note of even date, she

indicated that appellant was seen by her on that day. In a Form CA-17 of even date, Dr. Banks 

again diagnosed back spasm and provided work restrictions.

By decision dated January 3, 2020, OWCP accepted that the November 15, 2019 

employment incident occurred as alleged, but denied the claim finding that the medical evidence 

of record was insufficient to establish a medical diagnosis. It concluded, therefore, that the 

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

On January 28, 2020 appellant requested an oral hearing before a representative of 

OWCP’s Branch of Hearings and Review.

In a January 22, 2020 statement, appellant asserted that she had been working at the 

employing establishment since 2016 without an accident until November 14, 2019. She noted that 

performing her tasks at work on the night of November 14, 2019 gradually became difficult as she 

felt heavy straining of her back, eventually feeling a sharp pain in her back. After midnight, 

appellant experienced a burning sensation in her upper back. She immediately notified her 

supervisor that she injured her back. Appellant noted that Dr. Banks explained to her that the 

tearing and/or strain to the thoracic spinal would cause back muscle spasms. She asserted that she 

sustained an injury due to the accepted November 15, 2019 employment incident.

During the hearing, held on April 21, 2020, appellant testified that she was seen by both 

Drs. Rancour and Banks on November 15, 2019 following the accepted employment incident. She 

acknowledged that she had not been diagnosed with a medical condition due to her accepted 

employment incident. Appellant, however, asserted that Dr. Banks told her that she pulled her 

back muscle.

In an April 22, 2020 letter, Dr. Banks indicated that appellant was seen by her on 

November 15, 2019 for muscle spasms “likely secondary to muscle strain on her upper back.”

By decision dated June 22, 2020, the hearing representative affirmed OWCP’s January 3, 

2020 decision.
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LEGAL PRECEDENT

An employee seeking benefits under FECA4 has the burden of proof to establish the 

essential elements of his or her claim, including 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,5that 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.6 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.7

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

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

are two components involved in establishing 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 component is whether the employment incident 

caused a personal injury and can be established only by medical evidence.8 

The medical evidence required to establish a causal relationship between a claimed specific 

condition and an employment incident is rationalized medical opinion evidence.9 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 specific employment factors 

identified by the employee.10

ANALYSIS

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

medical condition causally related to the accepted November 15, 2019 employment incident.

 

4 Supra note 2.

5 F.H., Docket No. 18-0869 (issued January 29, 2020); J.P., Docket No. 19-0129 (issued April 26, 2019); Joe D. 

Cameron, 41 ECAB 153 (1989).

6 L.C., Docket No. 19-1301 (issued January 29, 2020); J.H., Docket No. 18-1637 (issued January 29, 2020); 

James E. Chadden, Sr., 40 ECAB 312 (1988).

7 P.A., Docket No. 18-0559 (issued January 29, 2020); K.M., Docket No. 15-1660 (issued September 16, 2016); 

Delores C. Ellyett, 41 ECAB 992 (1990).

8 T.H., Docket No. 19-0599 (issued January 28, 2020); K.L., Docket No. 18-1029 (issued January 9, 2019); John J. 

Carlone, 41 ECAB 354 (1989).

9 S.S., Docket No. 19-0688 (issued January 24, 2020); A.M., Docket No. 18-1748 (issued April 24, 2019); Robert G. 

Morris, 48 ECAB 238 (1996).

10 T.L., Docket No. 18-0778 (issued January 22, 2020); Y.S., Docket No. 18-0366 (issued January 22, 2020); 

Victor J. Woodhams, 41 ECAB 345, 352 (1989).
5

In medical reports dated November 15, 22, and December 16 2019, Dr. Banks consistently 

diagnosed back spasm. In an April 22, 2020 narrative report, Dr. Banks indicated that appellant 

was seen on November 15, 2019 for muscle spasms “likely secondary to muscle strain on her upper 

back.” The Board has held, however, that a muscle spasm is a symptom and not a compensable 

medical diagnosis.11 Furthermore, medical evidence that does not offer an opinion regarding the 

cause of an employee’s condition is of no probative value on the issue of causal relationship.12 

Thus, these reports are insufficient to establish appellant’s burden of proof.

In a medical report, after visit summary, and note dated November 15, 2019, Dr. Rancour 

noted that appellant presented with upper back pain, which occurred at work earlier that day when 

she was lifting a box of mail above her head. He diagnosed back spasm. As noted above, a muscle 

spasm is a symptom and not a compensable medical diagnosis.13 Likewise, the Board has also 

held that pain is a symptom, not a diagnosis.14 As this evidence lacks a firm diagnosis and a 

rationalized medical opinion regarding causal relationship, it is insufficient to establish appellant’s 

claim.15

As the record lacks rationalized medical evidence establishing a diagnosed medical 

condition causally related to the accepted November 15, 2019 employment incident, the Board 

finds that appellant has not met her burden of proof to establish her claim.16

Appellant may submit additional evidence, together 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 November 15, 2019 employment incident.

 

11 K.C., Docket No. 20-0683 (issued September 23, 2020); V.B., Docket No. 19-0643 (issued September 6, 2019); 

T.J., Docket No. 18-1500 (issued May 1, 2019); see also J.G., Docket No. 17-1382 (issued October 18, 2017).

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

13 See id. 

14 E.M., Docket No. 18-1599 (issued March 7, 2019).

15 See M.P., Docket No. 20-0996 (issued January 26, 2021).

16 The Board notes that the employing establishment issued a Form CA-16. A completed Form CA-16 authorization 

may constitute a contract for payment of medical expenses to a medical facility or physician, when properly executed. 

The form creates a contractual obligation, which does not involve the employee directly, to pay for the cost of the 

examination or treatment regardless of the action taken on the claim. See 20 C.F.R. § 10.300(c); J.G., Docket No. 

17-1062 (issued February 13, 2018); Tracy P. Spillane, 54 ECAB 608 (2003).
6

ORDER

IT IS HEREBY ORDERED THAT the June 22, 2020 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: June 4, 2021

Washington, DC

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board