United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

S.C., Appellant

and

DEPARTMENT OF THE INTERIOR, 

BUREAU OF RECLAMATION, Denver, CO, 

Employer

__________________________________________

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Docket No. 21-0637

Issued: August 12, 2021

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

PATRICIA H. FITZGERALD, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On March 15, 2021 appellant filed a timely appeal from a March 15, 2021 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 October 31, 2019 employment incident.

FACTUAL HISTORY

On November 4, 2019 appellant, then a 31-year-old letter secretary, filed a traumatic injury 

claim (Form CA-1) alleging that: on October 31, 2019 she sustained bruised muscles in her right 

 

1 5 U.S.C. § 8101 et seq.
2

arm; pain and numbness down to her fingers; sore right ribs; pain in her shoulder, back, neck, hip, 

knee, and ankle joint; and limited mobility in her arm, shoulder, and neck when she slipped and 

fell on a sheet of ice while in the performance of duty. She stopped work on the date of injury and 

returned to work on November 4, 2019.

On October 31, 2019 appellant underwent diagnostic testing by Dr. John M. Gilbert, a 

Board-certified diagnostic radiologist. In a cervical spine x-ray report dated October 31, 2019,

Dr. Gilbert provided an impression of normal cervical spine series with oblique and flexion and 

extension views. He reported that x-rays of the right shoulder and right scapula performed on 

October 31, 2019 were normal. Dr. Gilbert’s diagnostic reports noted appellant’s history of injury

of falling on the ice and experiencing pain in her right upper extremity status post a fall on ice on 

October 31, 2019.

Dr. Doris A. Kleinert, a Board-certified family practitioner, in a November 7, 2019 

physician’s report of workers’ compensation, noted a date of injury of October 31, 2019. She 

provided work-related diagnoses of neck, back, and right shoulder blade pain, right arm paresthesia 

without weakness. Dr. Kleinert advised that appellant could return to work with restrictions, for 

four hours per day as of November 8, 2019. In a November 8, 2019 narrative report, she discussed 

examination findings and reiterated her diagnosis of right shoulder and neck pain, and right upper 

limb paresthesia. Dr. Kleinert also provided assessments of unspecified fall and scapulalgia. On 

October 31, 2019 she referred appellant to physical therapy.

OWCP also received physical therapy notes dated from November 25, 2019 through 

January 20, 2020.

In a March 23, 2020 development letter, OWCP advised appellant of the deficiencies of 

her claim, requested additional factual and medical evidence, and provided a questionnaire for her 

completion. It afforded her 30 days to respond.

In an April 23, 2020 response to OWCP’s development letter, appellant, through counsel, 

explained that she was unable to obtain and submit a report from her physician because his office 

was limited due to the COVID-19 pandemic, and she was unable to complete the development 

questionnaire as she was required to look into records that she could not access at home during the 

pandemic. Counsel requested a 45-day extension to submit the required information. No 

additional evidence was received.

OWCP, by decision dated April 23, 2020, accepted that the October 31, 2019 employment 

incident occurred as alleged. However, it denied appellant’s traumatic injury claim, finding that 

he had not submitted medical evidence containing a medical diagnosis in connection with the 

accepted employment incident. OWCP explained that pain is a symptom, not a medical diagnosis. 

Consequently, it found that the requirements had not been met to establish an injury as defined by 

FECA.

Appellant, through counsel, requested reconsideration. She submitted a partial copy of a 

report by Dr. Kleinert.

Subsequently, appellant submitted the completed development questionnaire and a witness 

statement from her coworker.
3

By letter dated January 25, 2021, OWCP informed appellant that only a part of

Dr. Kleinert’s report had been received. It afforded her 30 days to submit Dr. Kleinert’s entire 

report.

OWCP received a complete copy of Dr. Kleinert’s November 26, 2020 report, noting that 

appellant presented for examination on November 7, 2019 for ongoing complaints of pain in her 

neck, back, and right shoulder blade, and right arm numbness and tingling. Dr. Kleinert also noted 

her history of injury on October 30, 2019, reported findings on examination, and reviewed 

diagnostic results. She diagnosed sprain of ligaments of the cervical spine and right shoulder, 

cervicalgia, scapulalgia, and paresthesia of the right upper limb. Based on her review of 

appellant’s history, physical examination findings, and imaging studies, Dr. Kleinert opined that 

the October 31, 2019 employment incident caused appellant’s diagnosed conditions. Regarding 

appellant’s cervical spine sprain and subsequent development of cervicalgia, she noted that a 

sprain of the ligaments of the cervical spine (cervical sprain) occurs when a muscle or ligament in 

the neck stretches or tears. This tearing and stretching can occur when a sudden movement, such 

as a fall, forces the neck to stretch or bend outside of its normal range of motion and places extreme 

pressure on the cervical spine. Extreme pressure on the cervical spine often results in chronic pain 

that is limited to the neck region, otherwise known as cervicalgia. Dr. Kleinert related that, in this 

case, appellant slipped on a sheet of ice and fell, landing primarily on her right shoulder blade. 

The abrupt fall caused a sudden, rapid back-and-forth movement of her neck (i.e., whiplash) and 

put extreme, excessive pressure on her neck and shoulder. This sudden back-and-forth movement 

was so forceful that it caused appellant’s neck to move outside of its normal range of motion and 

damaged the soil tissue in her neck. This resulted in a cervical sprain. As a result of this pressure 

on her cervical spine and subsequent soft tissue damage, as of November 7, 2019, appellant 

experienced pain that limited the neck region, i.e., cervicalgia. Dr. Kleinert maintained that apart 

from the October 31, 2019 work-related incident there was nothing in her history and no activities 

outside work that caused or contributed to her cervical sprain or cervicalgia. Regarding appellant’s 

right shoulder sprain, she indicated that a traumatic injury such as a fall causes a shoulder sprain 

when the tendons and ligaments stretch beyond their normal limits and become damaged or torn. 

The damage to the tendons and ligaments causes swelling, tenderness, and inflammation in the 

shoulder, resulting in a sprain. Dr. Kleinert again noted that the impact of her fall on her right 

shoulder caused the ligaments in her shoulder to be stretched beyond their normal limits. This 

damaged the tendons and ligaments and caused appellant’s right shoulder sprain. Dr. Kleinert 

maintained that the mechanism of injury, falling to the hard ground, and her symptoms of pain and 

painful range of motion corroborated this diagnosis. She noted that scapulalgia is a term that refers 

to pain in the region of the scapula or shoulder blades. This pain can be traumatic injury, such as 

a fall. When a person falls and lands on the shoulder blades, the shoulders absorb the force of the 

impact. The impact damages the soft tissues in the shoulder blades and swelling, bruising, 

tenderness, and inflammation, otherwise known as scapulalgia. Dr. Kleinert maintained that when 

appellant slipped onto a patch of ice and fell onto her right shoulder the soil tissues in the region 

became damaged because the right shoulder blade absorbed the impact of her body falling to the 

ground. This damage resulted in pain, swelling, tenderness, and inflammation. This damage also 

caused appellant’s scapulalgia. Dr. Kleinert defined appellant’s right upper limb paresthesia as a 

burning, tingling sensation that occurs when pressure is applied to a nerve. The sensation is often 

likened to pins and needles. Dr. Kleinert noted that paresthesia can be caused by traumatic injuries 

such as falls because such injuries cause the soft tissues in the body to swell. When a tissue 

becomes inflamed and swollen, the tissue puts increased pressure on nearby nerves. The increased 
4

pressure on the nerve results in paresthesia. Dr. Kleinert maintained that the impact of appellant 

falling onto her right shoulder and resulting sprain (described above) on her October 31, 2019

work injury caused swelling and inflammation in her right arm and shoulder. Consequently, the 

swollen tissue put increased pressure on the nerves in her right arm, causing paresthesia of the 

upper right limb. Dr. Kleinert related that appellant experiences numbness and tingling of the right 

arm/hand, which is consistent with this diagnosis. She concluded that appellant may return to parttime work with limitations as of November 7, 2019.

By decision dated March 15, 2021, OWCP modified in part its April 23, 2020 decision, but 

appellant’s claim remained denied. It found that while Dr. Kleinert provided diagnoses of right 

shoulder sprain and neck sprain, her opinion on causal relationship was of diminished probative 

value as it was more than one year after appellant’s October 31, 2019 employment incident, and 

thus, was not contemporaneous to the accepted work incident. 

LEGAL PRECEDENT

An employee seeking benefits under FECA2has 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,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 fact of injury has been established. There 

are two components involved in establishing fact of injury. The first component is that 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. The second component is 

whether the employment incident caused a personal injury and can be established only by medical 

evidence.6

 

2

Id.

3 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).

4 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).

5 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).

6 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). 
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The medical evidence required to establish causal relationship between a claimed specific 

condition and an employment incident is rationalized medical opinion evidence.7 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.8

ANALYSIS

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

In a November 26, 2020 medical report, Dr. Kleinert opined that the accepted October 31, 

2019 employment incident caused appellant’s cervical spine sprain, cervicalgia, right shoulder 

sprain, scapulalgia, and right upper limb paresthesia. She reviewed diagnostic reports and 

provided findings on physical examination. Dr. Kleinert discussed the mechanism of injury for 

this traumatic injury claim. She noted that a cervical spine sprain occurs when a muscle or 

ligament in the neck stretches or tears. This tearing and stretching can occur when a sudden 

movement, such as a fall, forces the neck to stretch or bend outside of its normal range of motion 

and places extreme pressure on the cervical spine. Dr. Kleinert maintained that the impact of 

appellant’s fall onto her right shoulder caused the ligaments in her shoulder to be stretched beyond 

their normal limits. This damaged the tendons and ligaments and caused her right shoulder sprain. 

Dr. Kleinert related that appellant’s mechanism of injury, falling to the hard ground, and her

symptoms of pain and painful range of motion corroborated her diagnosis. She noted that 

scapulalgia referred to pain in the region of the scapula or shoulder blades. This pain can be 

traumatic injury, such as a fall. When a person falls and lands on the shoulder blades, the shoulders 

absorb the force of the impact. The impact damages the soft tissues in the shoulder blades and 

swelling, bruising, tenderness, and inflammation, otherwise known as scapulalgia. Dr. Kleinert 

indicated that since appellant’s right shoulder blade absorbed the impact of her body falling to the 

ground, the soil tissues in the region became damaged. This damage resulted in pain, swelling, 

tenderness, inflammation, and scapulalgia. Dr. Kleinert defined right upper limb paresthesia as a 

burning, tingling sensation that occurs when pressure is applied to a nerve. The sensation is often 

likened to pins and needles. Paresthesia can be caused by traumatic injuries such as falls because 

such injuries cause the soft tissues in the body to swell. When a tissue becomes inflamed and 

swollen, the tissue puts increased pressure on nearby nerves. The increased pressure on the nerve 

results in paresthesia. Dr. Kleinert advised that the impact and resulting sprain of appellant’s fall 

onto her right shoulder and arm caused swelling and inflammation in her right arm and shoulder. 

Consequently, she advised that the swollen tissue put increased pressure on the nerves in her right 

arm, causing paresthesia of the upper right limb. Dr. Kleinert maintained that appellant’s

numbness and tingling of the right arm/hand was consistent with such diagnosis.

 

7 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).

8 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).
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The Board finds that her report provides sufficient rationale to require further development 

of the case record by OWCP.9 Dr. Kleinert referenced objective medical findings demonstrating 

injury, expressed her opinion on causal relationship within a reasonable degree of medical 

certainty, and provided a pathophysiologic explanation as to the mechanism by which the accepted 

October 31, 2019 employment incident would have resulted in her diagnosed conditions. 

It is well established that proceedings under FECA are not adversarial in nature and while 

the claimant has the burden of proof to establish entitlement to compensation, OWCP shares 

responsibility in the development of the evidence to see that justice is done.10

The case shall, therefore, be remanded to OWCP for further development of the medical 

evidence in order to determine whether appellant sustained a medical condition causally related to 

the October 31, 2019 employment incident. On remand, OWCP shall prepare a statement of 

accepted facts and refer appellant to specialist in the appropriate field of medicine for a second 

opinion examination. The referral physician shall provide a well-rationalized opinion as to 

whether the accepted employment incident caused, aggravated, or accelerated appellant’s 

diagnosed conditions. If the referral physician opines that the diagnosed conditions are not 

causally related to the employment incident, he or she must provide a rationalized explanation as 

to why their opinion differs from that articulated by Dr. Kleinert. Following this and other such 

further development as deemed necessary, OWCP shall issue a de novo decision on appellant’s 

traumatic injury claim.

CONCLUSION

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

 

9 See B.F., Docket No. 20-0990 (issued January 13, 2021); Y.D., Docket No. 19-1200 (issued April 6, 2020).

10 Id.; K.P., Docket No. 18-0041 (issued May 24, 2019).
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ORDER

IT IS HEREBY ORDERED THAT the March 15, 2021 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: August 12, 2021

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board