United States Department of Labor

Employees’ Compensation Appeals Board

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A.B., Appellant

and

U.S. POSTAL SERVICE, AUGUSTA POST 

OFFICE, Augusta, ME, Employer

__________________________________________

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Docket No. 20-1017

Issued: June 11, 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 April 12, 2020 appellant filed a timely appeal from a December 19, 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.2

ISSUE

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

condition causally related to the accepted October 10, 2019 employment incident.

 

1 5 U.S.C. § 8101 et seq.

2 The Board notes that, following the December 19, 2019 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

FACTUAL HISTORY

On October 16, 2019 appellant, then a 32-year-old mail processing clerk, filed a traumatic 

injury claim (Form CA-1) alleging that on October 10, 2019 she sustained a lower back injury as 

a result of picking up a heavy parcel from within a container while in the performance of duty. 

She stopped work on that date and accepted a modified clerk job offer effective November 1, 2019.

In a work excuse note dated October 10, 2019, Dr. Laura Caron, a family medicine 

specialist, stated that appellant would be off work on that date and October 11, 2019 due to injury. 

She recommended that appellant return to work on October 14, 2019. 

In a work excuse note dated October 15, 2019, Dr. Caron stated that appellant would be 

off work until October 30, 2019 for an acute injury. 

By letter dated October 18, 2019, the employing establishment challenged appellant’s 

claim on the basis that no medical diagnosis had been provided.

In a report dated October 10, 2019, Dr. Caron indicated that she examined appellant for 

complaints of stomach pain. Appellant told Dr. Caron that she had developed abdominal pain 

while leaning forward and lifting something heavy at work “two days” prior. She stopped lifting 

and stood when she developed a sharp shooting pain in the left lower quadrant. Appellant sat for 

10 to 15 minutes, then was able to continue moving boxes, though she experienced pain with any 

bending at the waist and lifting anything heavier than paper. On physical examination Dr. Caron 

observed a normal back posture with mild hypertonicity of the left lower lumbar spine around L4 

with a trigger point, as well as tenderness lateral to the umbilicus, worse on activation of the 

abdominal wall. She diagnosed as related to this encounter morbid obesity and abdominal wall 

pain. Under the heading “Plan,” Dr. Caron provided an additional diagnosis of abdominal wall 

muscle sprain. In a follow-up report dated October 15, 2019, she examined appellant for 

complaints of back pain. Dr. Caron noted that appellant experienced worsening back pain after an 

injury at work on October 10, 2019. Appellant advised Dr. Caron that when she returned to work

after having been off for three days, she experienced a return of the pain at work the night of 

October 14, 2019, after feeling a “pop.” She finished her shift, but could hardly walk afterward. 

On physical examination Dr. Caron observed hypertonicity and mild tenderness of the right lumbar 

spine, marked hypertonicity and hypersensitivity of the left lumbar spine, decreased rotation to the 

right, full, but painful hip flexion, and reduced knee extension and flexion secondary to pain. She 

diagnosed muscle spasm and lumbago. Under the heading “Plan,” Dr. Caron diagnosed 

mechanical low back pain. 

In a form report dated October 15, 2019, Dr. Caron diagnosed low back pain and cramp 

and spasm related to an injury on October 10, 2019. She checked a box, indicating that the 

problem was work related and checked a box recommending no return to work. 

In a duty status report (Form CA-17) dated October 30, 2019, Dr. Caron diagnosed muscle 

“spasm (L) back” and stated that appellnt could return to work with restrictions on 

October 30, 2019. 
3

In a development letter dated November 9, 2019, OWCP informed appellant that additional 

medical evidence was needed to establish her claim. It advised her of the type of factual and 

medical evidence needed. OWCP afforded appellant 30 days to submit the necessary evidence.

In a follow-up report dated October 30, 2019, Dr. Caron evaluated appellant for back pain 

related to a workplace injury and potential return to work. Appellant noted that her pain was not 

as severe, but still consistent, and she had not lifted anything more than a gallon of milk. On 

physical examination Dr. Caron observed increased lumbar lordosis, minimal tenderness of the 

right side, hypertonicity of the left lumbar spine into the left gluteus, almost full rotation to the left 

with discomfort, full rotation to the right passively, and inability to actively rotate to the right due 

to pain. She diagnosed lumbago, muscle spasm, morbid obesity, and other sleep disorders. Under 

the heading “Plan,” Dr. Caron noted that appellant’s lumbago had improved by 50 percent. She 

recommended appellant return to work at light duty with restrictions.

By decision dated December 19, 2019, OWCP denied appellant’s traumatic injury claim, 

finding that she had not submitted medical evidence containing a medical diagnosis in connection 

with her accepted employment incident. It concluded, therefore, that the requirements had not 

been met to establish an injury as defined under FECA.

LEGAL PRECEDENT

An employee seeking benefits under FECA3 has the burden of proof to establish the 

essential elements of his or her claim, including the fact 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,4that 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.5 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.6

In order to determine whether an employee actually sustained an 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, which must be considered in conjunction with one 

another. The first component to be established is that the employee actually experienced the 

employment incident, which is alleged to have occurred.7 The second component is whether the 

 

3 Supra note 1.

4 S.B., Docket No. 17-1779 (issued February 7, 2018); J.P., 59 ECAB 178 (2007); Joe D. Cameron, 41 ECAB 

153 (1989).

5

J.M., Docket No. 17-0284 (issued February 7, 2018); R.C., 59 ECAB 427 (2008); James E. Chadden, Sr., 40 

ECAB 312 (1988).

6 K.M., Docket No. 15-1660 (issued September 16, 2016); L.M., Docket No. 13-1402 (issued February 7, 2014); 

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

7

Id.; Elaine Pendleton, 40 ECAB 1143 (1989).
4

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

evidence.8

Causal relationship is a medical question that requires rationalized medical opinion 

evidence to resolve the issue.9 The opinion of the physician must be based on a complete factual 

and medical background of the claimant, 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 incident identified by the claimant.10

ANALYSIS

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

condition causally related to the accepted October 10, 2019 employment incident.

Dr. Caron, in her October 10, 2019 medical report, indicated that appellant had developed 

abdominal pain while leaning forward and lifting something heavy at work two days prior. Under 

the heading “Plan,” she provided a diagnosis of abdominal wall muscle sprain. While abdominal 

wall muscle sprain is an acceptable diagnosis under FECA, it appears that, based on the history of 

injury provided by appellant, Dr. Caron’s diagnosis was related to a separate work incident “two 

days” prior to the accepted employment incident of October 10, 2019 as related to this diagnosed 

condition.11 As such, the diagnosis contained in her October 10, 2019 report, appearing to be 

related to a separate incident two days prior to the accepted employment incident of October 10, 

2019, is insufficient to establish a diagnosis in connection with the accepted employment incident.

In her October 10 15, and 30, 2019 reports, Dr. Caron provided assessments of abdominal 

wall pain, mechanical low back pain, low back pain, and lumbago. Under FECA, the assessment 

of pain is not considered a diagnosis, as pain merely refers to a symptom of an underlying 

condition.12 Dr. Caron also provided assessments of muscle spasm, cramp and spasm, muscle 

spasm of the left back, and muscle spasm. Similarly, to the assessment of pain, cramp, and spasm 

are symptoms and not specific medical diagnoses.13 Therefore, these reports and forms, lacking 

firm diagnoses of any condition in connection with the accepted employment incident of 

October 10, 2019, are insufficient to establish appellant’s claim.

 

8 K.L., Docket No. 18-1029 (issued January 9, 2019). See Shirley A. Temple, 48 ECAB 404, 407 (1997); John J. 

Carlone 41 ECAB 354, 356-57 (1989).

9 M.S., Docket No. 19-1096 (issued November 12, 2019); Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000).

10 R.S., Docket No. 19-1484 (issued January 13, 2020); Leslie C. Moore, 52 ECAB 132 (2000).

11 See J.D., Docket No. 16-0887 (issued November 4, 2016; M.E., Docket No. 14-399 (issued June 20, 2014); C.G., 

Docket No. 11-1602 (issued March 23, 2012).

12 The Board has consistently held that pain is a symptom, not a compensable medical diagnosis. See T.W., Docket 

No. 20-0767 (issued January 13, 2021); M.V., Docket No. 18-0884 (regarding lumbago) (issued December 28, 2018);

P.S., Docket No. 12-1601 (issued January 2, 2013); C.F., Docket No. 08-1102 (issued October 10, 2008).

13 See K.C., Docket No. 20-0683 (issued September 23, 2020); M.H., Docket No. 18-0873 (issued December 18, 

2019); J.S., Docket No. 19-0863 (issued November 4, 2019); V.B., Docket No. 19-0643 (issued September 6, 2019).
5

The Board finds that appellant has not submitted rationalized, probative medical evidence 

sufficient to establish a diagnosed medical condition in connection with her October 10, 2019 

employment incident.14 Appellant, therefore, has not met her burden of proof.

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 her burden of proof to establish a diagnosed 

medical condition causally related to the accepted October 10, 2019 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the December 19, 2019 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: June 11, 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

 

14 See T.J., Docket No. 18-1500 (issued May 1, 2019); see D.S., Docket No. 18-0061 (issued May 29, 2018).