United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

R.C., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

BROCKTON VA MEDICAL CENTER, 

Brockton, MA, Employer

__________________________________________

)

)

)

)

)

)

)

)

)

Docket No. 22-0888

Issued: October 4, 2023

Appearances: Case Submitted on the Record

Alan J. Shapiro, Esq., for the appellant1

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JAMES D. McGINLEY, Alternate Judge

JURISDICTION

On May 26, 2022 appellant, through counsel, filed a timely appeal from a May 3, 2022

merit decision of the Office of Workers’ Compensation Programs (OWCP). Pursuant to the 

Federal Employees’ Compensation Act2(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board 

has jurisdiction to consider the merits of this case. 

1

In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for legal 

or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. § 501.9(e). 

No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An attorney or 

representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject to fine or 

imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a 

representative, prior to approval by the Board, may be reported to appropriate authorities for investigation.

2

5 U.S.C. § 8101 et seq.
2

ISSUE

The issue is whether appellant has met his burden of proof to establish that the acceptance 

of his claim should be expanded to include Bell’s palsy and/or a low back condition as causally 

related to or as a consequence of his accepted December 19, 2019 employment injury.

FACTUAL HISTORY

On February 11, 2020 appellant, then a 67-year-old acting environmental care specialist, 

filed a traumatic injury claim (Form CA-1) alleging that on December 19, 2019 he injured his left 

knee moving and lifting boxes while in the performance of duty. OWCP accepted his claim for 

complex tear of the medial meniscus of the left knee.

In medical reports dated December 23, 2019, and January 6 and 9, 2020, Kristen Antoine, 

a nurse practitioner, diagnosed appellant with a left knee sprain due to lifting heavy boxes at work 

on December 19, 2019.

In an initial evaluation report dated February 10, 2020, Jennifer Desalvo, a physical 

therapist, noted that appellant complained of left knee pain due to a December 19, 2019 lifting 

incident. She further noted that he related complaints of low back pain, which he attributed to 

favoring his left lower extremity. 

In a report dated February 11, 2020, Dr. Edward M. Phillips, a Board-certified physiatrist, 

discussed appellant’s complaints of left knee pain and compensatory pain in the right leg and back. 

He performed a physical examination, which revealed an antalgic gait favoring the left leg, 

minimal crepitus, medial knee pain with valgus stress, and limited lumbar extension due to pain. 

Dr. Phillips reviewed diagnostic studies including x-rays of the left knee obtained on 

December 23, 2019, which were negative for fracture, and prior computed tomography (CT) and

magnetic resonance imaging (MRI) of the lumbar spine dated October 23 and November 22, 2017, 

respectively, which revealed anterolisthesis of L4 on L5, disc bulging from L2 through L5, and a 

left paracentral disc extrusion at L5-S1. He diagnosed a possible meniscal tear and sprain of the 

medial collateral ligament and recommended an MRI scan of the left knee. 

A report of MRI scan of the left knee dated February 12, 2020 revealed a complex tear of 

the posterior horn body of the medial meniscus.

On March 12, 2022 Dr. Courtney Dawson, a Board-certified orthopedic surgeon, 

performed an OWCP-authorized left knee arthroscopy with partial medial and lateral 

meniscectomies.

In a postoperative progress note dated March 27, 2022, Dr. Dawson noted that appellant’s 

left knee pain had resolved, but that he was using a cane for back pain. She further noted that he 

developed Bell’s palsy that week. Dr. Dawson performed a physical examination, which revealed 

a right-sided facial droop consistent with Bell’s palsy, healed surgical scars, and painless range of 

motion of the left knee. She prescribed an at-home strengthening program, and recommended that 

appellant avoid climbing ladders, kneeling, and crawling for three to four weeks.
3

In a report dated April 28, 2020, Dr. Michael Klein, a Board-certified family medicine

specialist, noted that appellant had undergone surgery to his left knee, and was diagnosed with 

Bell’s palsy five days later. He also noted that, while participating in physical therapy, following 

appellant’s left knee surgery, appellant experienced right-sided lower back pain due to limping to 

compensate for the injured left leg. Dr. Klein performed a physical examination, which revealed

an antalgic gait favoring the left leg, limited left knee flexion, and marked palsy of the seventh 

cranial nerve. He diagnosed Bell’s Palsy and a tear of meniscus of the left knee. Dr. Klein related 

that Bell’s palsy had many etiologies, but that it “occurring so close to surgery would seem to point 

to some peri-surgical event whether systemic stress or a viral infection as the inciting event.” 

In a separate narrative report of even date, Dr. Klein noted that there was no definitive test 

to determine the cause of Bell’s palsy, but “an argument could be made” that the condition was 

related to appellant’s initial left knee injury because postoperative stress and peri-operative viral 

infection had been correlated with Bell’s palsy. He recommended that appellant remain out of 

work until the Bell’s palsy resolved because appellant could not safely wear a mask, which was 

necessary due to the COVID-19 pandemic.

In a follow-up report dated June 18, 2020, Dr. Klein noted that appellant related that 

appellant experienced pain and multiple palpable muscle spasms in his lower back during physical 

therapy, which appellant attributed to a severely antalgic gait after his knee injury. He diagnosed 

Bell’s palsy, lumbar back pain with radiculopathy affecting the left lower extremity, and a left 

knee meniscus tear. Dr. Klein agreed that appellant’s Bell’s palsy “could very well have arisen”

from his employment injury.

In a separate narrative report of even date, Dr. Klein requested that the acceptance of 

appellant’s claim be expanded to include low back pain and Bell’s palsy. He noted that Bell’s 

palsy had multiple triggers and was usually spontaneous, but could “certainly be triggered” by 

physiological stress. Dr. Klein opined that appellant’s knee injury, surgery, and recovery “could 

have provided such a trigger.” He further opined that appellant had a compensatory back injury 

due to gait changes related to his left knee injury. Dr. Klein concluded that there was a “clear 

starting point to the medical troubles which stemmed from [appellant’s]December 19, 2019 injury 

and that his knee injury, back pain, and Bell’s palsy can all be traced back to this injury as the 

initial cause within a reasonable degree of medical certainty.”

In a statement dated August 31, 2020, appellant indicated that hobbling and 

overcompensating for his injured left leg caused a longstanding back ailment3to become more 

prevalent and intensify, and that he needed a cane, physical therapy, and back massages for his 

lower back symptoms. He also noted that he developed Bell’s palsy while recovering from surgery 

to the left knee.

In a development letter dated September 1, 2020, OWCP informed appellant that the 

evidence was insufficient to warrant expansion of the acceptance of his claim to include Bell’s 

3 Appellant has a previously accepted October 16, 2017 traumatic injury claim for lower back strain under OWCP 

File No. xxxxxx943. His claims have not been administratively combined by OWCP.
4

palsy and a lower back condition. It advised him of the factual and medical evidence needed to 

establish a consequential claim and afforded him 30 days to submit the necessary evidence.

In a September 16, 2020 report, Dr. Todd Fellars, a Board-certified orthopedic surgeon 

serving as an OWCP district medical adviser (DMA), reviewed a statement of accepted facts and 

the medical record. He opined that appellant’s Bell’s palsy and low back condition were not a 

consequence of the accepted December 19, 2019 employment injury. Dr. Fellars noted that there 

was a temporal association, but found that the conditions were idiopathic with a date of onset 

around the time of the knee surgery.

In a narrative report dated November 5, 2020, Dr. Sadie Elisseou, a Board-certified 

internist, noted that she had treated appellant for the past year. She indicated that she had reviewed 

various physical therapy notes which documented complaints of lower back pain due to difficulty 

ambulating on the left leg. Dr. Elisseou further indicated that Bell’s palsy had multiple potential 

causes, including herpes simplex virus activation and general anesthesia during surgery. She noted 

that immediate postoperative facial nerve paralysis was rare and cited various case studies 

regarding Bell’s palsy.

In a medical report dated November 9, 2020, Dr. Klein indicated that appellant related a 

substantial amount of pain in his back, which Dr. Klein opined that was due to an antalgic gait. 

He also diagnosed reflex Bell’s palsy, which he opined was due to surgery for the accepted left 

knee injury.

In a separate narrative report of even date, Dr. Klein indicated that he disagreed with the 

opinion of OWCP’s DMA. He again opined that appellant’s left knee surgery triggered his Bell’s 

palsy and his antalgic gait triggered back pain. Dr. Klein attributed appellant’s meniscal tear of 

the knee, the lumbar pain, and Bell’s palsy to the accepted December 19, 2019 employment injury.

By decision dated April 19, 2021, OWCP denied expansion of the acceptance of 

appellant’s claim to include a consequential low back condition or Bell’s palsy.

OWCP continued to receive evidence, including a January 13, 2022 narrative report by

Dr. Elisseou, who diagnosed appellant with back pain and Bell’s palsy. Dr. Elisseou opined that

knee pain can cause new back pain or worsen underlying back pain by causing a change in gait, 

leading to malalignment of the spine, muscular spasm of the back, pinched peripheral nerves, or a 

flare in degenerative disc disease and/or arthritis of the spine. She explained that there was an 

association between Bell’s palsy and general anesthesia or herpessimplex virus activation, but that 

postoperative facial paralysis was rare, and the cause of Bell’s palsy was generally unknown.

Dr. Elisseou opined that it was more than likely that the severe physical stress of appellant’s left 

knee surgery led to increased pain and circulation of inflammatory markers in the body, which 

impaired his immunity and triggered an episode of acute Bell’s palsy. 

On January 31, 2022 appellant, through counsel, requested reconsideration of OWCP’s 

April 19, 2021 decision.

In a letter dated February 23, 2022, the employing establishment controverted appellant’s 

request for reconsideration.
5

By decision dated May 3, 2022, OWCP denied modification of its April 19, 2021 decision. 

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.4

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.5 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.6 The weight of medical evidence is determined by its reliability, 

its probative value, its convincing quality, the care of analysis manifested, and the medical 

rationale expressed in support of the physician’s opinion.7

In discussing the range of compensable consequences, once the primary injury is causally 

connected with the employment, the question is whether compensability should be extended to a 

subsequent injury or aggravation related in some way to the primary injury. The rules that come 

into play are essentially based upon the concepts of direct and natural results and of the claimant’s 

own conduct as an independent intervening cause. The basic rule is that a subsequent injury, 

whether an aggravation of the original injury or a new and distinct injury, is compensable if it is 

the direct and natural result of a compensable primary injury. 8

In a case in which 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.9

4

See N.U., Docket No. 22-1329 (issued April18, 2023); M.M., Docket No. 22-0037 (issued October 12, 2022);

C.W., Docket No. 21-0017 (issued December 28, 2021); T.B., Docket No. 20-0182 (issued April23, 2021); JajaK. 

Asaramo, 55 ECAB 200, 204 (2004)

5 L.R., Docket No. 21-0018 (issued February 17, 2023); T.K., Docket No. 18-1239 (issued May 29, 2019).

6 D.L., Docket No. 21-0047 (issued February 22, 2023); R.P., Docket No. 18-1591 (issued May8, 2019); Victor J. 

Woodhams, 41 ECAB 345 (1989).

7

Id. 

8 D.L., supra note 6; V.K., Docket No. 19-0422 (issued June 10, 2020).

9 Federal (FECA) Procedure Manual, Part 2 --Claims, Causal Relationship, Chapter 2.805.3e (January 2013); G.D., 

Docket No. 20-0966 (issued July 21, 2022); J.L., Docket No. 20-0717 (issued October 15, 2020).
6

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish that the 

acceptance of his claim should be expanded to include Bell’s palsy and/or a lumbar condition as 

causally related to or as a consequence of the December 19, 2019 employment injury.

In her January 13, 2022 report, Dr. Elisseou diagnosed back pain and Bell’s palsy. The 

Board has held that pain is a symptom and not a compensable medical diagnosis.10 Regarding the 

diagnosis of Bell’s palsy, Dr. Elisseou opined that it was more than likely that the severe physical 

stress of appellant’s left knee surgery led to increased pain and circulation of inflammatory markers 

in the body, causing impaired immunity which “can trigger” an acute illness, such as Bell’s palsy. 

The Board notes that the medical record does not contain any indication that he was diagnosed 

with a viral infection on or about the date of his authorized knee surgery. Moreover, Dr. Elisseou

did not explain how the authorized left knee surgery caused Bell’s palsy, other than to note that it 

led to increased pain and circulation of inflammatory markers, which impairedimmunity and could

have triggered an acute illness. The Board has held that medical opinions that suggest that a 

condition “could” be caused by an event are speculative or equivocal in character and have limited 

probative value.11 Therefore, the Board finds Dr. Elisseou’s opinion to be speculative in nature

and lacking sufficient medical rationale to demonstrate that the conclusion reached regarding 

appellant’s condition was sound, logical, and rational.

12

 For these reasons, the Board finds that 

her January 13, 2022 report is insufficient to establish his expansion claim.

In her November 5, 2020 report, Dr. Elisseou provided her review of medical reports and 

noted that appellant wanted a report regarding his left knee pain, low back pain, and Bell’s palsy. 

As noted above, the Board had held that pain is a symptom and not a compensable medical 

diagnosis.13 Moreover, Dr. Elisseou reviewed the medical evidence, but did not explain 

physiologically how the accepted employment injury resulted in Bell’s palsy. The Board has held 

that a report is of limited probative value regarding causal relationship if it does not contain 

medical rationale explaining how a given medical condition is causally related to the accepted 

employment injury.

14

 Thus, Dr. Elisseou’s November 5, 2020 narrative report is also insufficient 

to meet appellant’s burden of proof to establish expansion of the acceptance of his claim.

10 R.N., Docket No. 19-1004 (issued October 18, 2019); A.T., Docket No. 19-0410 (issued August 13, 2019); Robert 

Broome, 57 ECAB 339, 342 (2004).

11 N.H., Docket No. 21-1133 (issued February 25, 2022); see D.B., Docket No. 20-0775 (issued July 28, 2021); 

J.W., Docket No. 18-0678 (issued March 3, 2020).

12 See L.M., Docket No. 17-0279 (issued January 26, 2018); B.S., Docket No. 15-0002 (issued February 27, 2015); 

K.W., 59 ECAB 271 (2007).

13 Supra note 10.

14 See S.S., Docket No. 21-1140 (issued June 29, 2022); A.P., Docket No. 20-1668 (issued March2, 2022); D.S., 

Docket No. 21-0673 (issued October 10, 2021); R.A., Docket No. 20-0969 (issued August9, 2021); see also T.M., 

Docket No. 08-0975 (issued February 6, 2009) (a medical report is of limited probative value on the issue of causal 

relationship if it contains a conclusion regarding causal relationship which is unsupported by medical rationale).
7

In his reports dated April 28, June 18, and November 9, 2020, Dr. Klein diagnosed Bell’s 

palsy, low back pain, and left-sided lumbar radiculopathy. Regarding the low back, he opined that 

an antalgic gait following the authorized left knee surgery triggered low back pain and 

radiculopathy. While Dr. Klein attributed appellant’s low back condition to appellant’s accepted 

left knee injury, the Board finds that he did not offer medical rationale explaining how the accepted 

employment injury caused a low back condition.

15

 He did not explain the mechanism of injury of 

how overcompensating for appellant’s left knee injury contributed to the development of an 

additional low back condition.

16

 The Board has held that medical evidence that states a conclusion, 

but does not offer a rationalized medical explanation regarding the cause of an employee’s 

condition is of limited probative value on the issue of causal relationship.17 Regarding the 

diagnosis of Bell’s palsy, Dr. Klein opined that physiological stress associated with the authorized 

left knee surgery could have triggered the condition. As noted above, the Board has held that 

medical opinions that suggest that a condition “could” be caused by an event are speculative or 

equivocal in character and have limited probative value.18 Accordingly, Dr. Klein’s reports are

also insufficient to meet appellant’s burden of proof.

Dr. Phillips, in his February 11, 2020 report, noted that appellant complained of 

compensatory back pain. Similarly, in her March 27, 2020 report, Dr. Dawson noted that he was 

using a cane due to back pain and had right-sided facial droop consistent with Bell’s palsy. 

However, neither of these reports contain an opinion as to the cause of these conditions. The Board 

has held that a report is of no probative value regarding causal relationship if it does not provide 

an opinion on causal relationship.19 As such, neither the February 11, 2020 report from

Dr. Phillips, nor the report dated March 27, 2020 from Dr. Dawson are sufficient to meet 

appellant’s burden of proof.

The remaining evidence of record consists of notes by physical therapists and a nurse 

practitioner. Certain healthcare providers such as physician assistants, physical therapists, nurse 

practitioners, and social workers are not considered “physician[s]” as defined under FECA.20 

15 Id.

16 See S.S., supra note 14; S.D., Docket No. 21-0085 (issued August 9, 2021); see also M.B., Docket No. 19-1655 

(issued April 7, 2020).

17 Supra note 10; P.J., Docket No. 18-1738 (issued May 17, 2019); D.H., Docket No. 17-1913 (issued 

December 13, 2018).

18 J.W., supra note 11.

19 A.H., Docket No. 18-1632 (issued June 1, 2020); L.B., Docket No. 18-0533 (issued August27, 2018); D.K., 

Docket No. 17-1549 (issued July 6, 2018).

20 Section 8101(2) provides that under FECA the term physician includes surgeons, podiatrists, dentists, clinical 

psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined 

by the applicable state law. 5 U.S.C. § 8101(2); 20 C.F.R. § 10.5(t). See supra note 9 at Chapter 2.805.3a(1) 

(January2013); DavidP. Sawchuk, 57 ECAB 316, 320 n.11 (2006) (lay individuals such as physician assistants, 

nurses, and physical therapists are not competent to render a medical opinion under FECA); see also R.L., Docket No. 

19-0440 (issued July 8, 2019) (nurse practitioners and physical therapists are not considered physicians under FECA).
8

Consequently, their medical findings and/or opinions will not suffice for purposes of establishing 

entitlement to FECA benefits. 

Moreover, appellant submitted diagnostic studies in support of his claim. The Board has 

held that diagnostic studies, standing alone, lack probative value as they do not address whether 

the employment factors caused any of the diagnosed conditions.21 As such, this evidence is also 

insufficient to establish appellant’s claim.22

Appellant has not submitted rationalized medical evidence establishing that the acceptance 

of his claim should be expanded to include Bell’s palsy and/or a low back condition as causally 

related to or as a consequence of his accepted December 19, 2019 employment injury and therefore 

has not met his 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 his burden of proof to expand the acceptance of 

his claim to include Bell’s palsy and/or a low back condition as causally related to or as a 

consequence of his December 19, 2019 employment injury.

21 V.L., Docket No. 20-0884 (issued February 12, 2021); R.C., Docket No. 19-0376 (issued July 15, 2019).

22 D.P., Docket No. 19-1295 (issued March 16, 2020); G.S., Docket No. 18-1696 (issued March 26, 2019); see 

M.M., Docket No. 17-1641 (issued February 15, 2018); K.J., Docket No. 16-1805 (issued February 23, 2018); 

David P. Sawchuk, supra note 20.
9

ORDER

IT IS HEREBY ORDERED THAT the May 3, 2022 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: October 4, 2023

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board

James D. McGinley, Alternate Judge

Employees’ Compensation Appeals Board