U. S. DEPARTMENT OF LABOR
Employees’ Compensation Appeals Board
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In the Matter of CARRIE L. DENNISON and DEPARTMENT OF THE NAVY,
NORFOLK NAVAL SHIPYARD, Portsmouth, VA
Docket No. 97-2798; Submitted on the Record;
Issued August 25, 1999
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DECISION and ORDER
Before WILLIE T.C. THOMAS, MICHAEL E. GROOM,
A. PETER KANJORSKI
The issue is whether appellant’s fibromyalgia and myofascial pain in her neck, shoulder and right arm are causally related to factors of her federal employment.
On May 19, 1996 appellant, then a 54-year-old supply clerk, filed a claim for an occupational disease, Form CA-2, alleging that she sustained severe pain in her shoulders, neck and right arm and was unable to use her right hand for more than two to three minutes due to the constant use of computers and typewriters on her job. Appellant retired from her federal employment on October 1, 1993. The SF-50 form stated that appellant retired to take advantage of the employing establishment’s separation incentive. In a report dated May 3, 1996, Dr. Robert B. Hansen, a Board-certified psychiatrist and neurologist with a subspecialty in critical care medicine, noted that he initially saw appellant in March 1993 and treated her several times in 1994 for fibromyalgia and stated that it was quite likely that appellant’s symptoms could be related to her federal employment.
By letter dated July 30, 1996, the Office of Workers’ Compensation Programs requested additional information from appellant to establish her claim including a narrative report from her physician explaining the specific factors at work that caused her condition.
In a statement dated August 29, 1996, appellant stated that she developed fibromyalgia as a result of many years of use of computers, adding machines, cash registers and typewriters at her job with the employing establishment and the way she sat while doing her job.
In a report dated August 27, 1996, Dr. Bruce I. Tetalman, appellant’s treating physician and a Board-certified physiatrist, diagnosed myofascial pain secondary to her employment. He stated that appellant worked on computers and operated a cash register. Dr. Tetalman also noted that, to operate the computers, appellant was in a sitting position all day and, while operating the cash register, was sometimes sitting and sometimes standing. He reported that appellant stated that the position she typed in was uncomfortable because of the chair and that appellant either operated the computers or used the cash register 40 hours a week. Dr. Tetalman stated:
“I feel that the patient’s condition, myofascial pain, is directly related to her operating the computer and cash register because of the inappropriate posture. Her condition was somewhat compounded by the stress she had at work. The patient relates deadlines that she would have to meet. Myofascial pain is often triggered by a combination of repetitive work and stress. This is what appears to be the case with [appellant].”
By decision dated November 12, 1996, the Office denied the claim, stating that the evidence of record failed to establish that the claimed medical condition or disability is causally related to the accepted activities or employment factors.
By letter dated December 7, 1996, appellant requested a written review of the record by an Office hearing representative and submitted another report from Dr. Tetalman dated December 9, 1996. In his December 9, 1996 report, he stated that appellant complained of pain prior to her retirement, that the pain was initially in the shoulder, arm and upper extremity and became progressive. He noted that appellant mentioned these complaints to her former treating doctors when in Southeastern Neurology. Dr. Tetalman stated:
“It is not unusual to have myofascial pain which under stress causes a secondary fibromyalgia. The myofascial pain is clearly related to operating on computers and typewriters and it is not unusual to see myofascial pain resulting from a repetitive stress disorder.
“There are no blood tests or objective findings with fibromyalgia as well as myofascial pain. Consequently, it is not surprising that the patient would be misdiagnosed in light of negative blood work and x-rays. Although the patient complained of joint pain, one must realize that all muscles attach to part of the joint.”
He concluded that appellant’s condition of myofascial pain started “around the time, certainly before retirement,” became progressive and appellant subsequently developed a secondary fibromyalgia.
By letter dated February 21, 1997, appellant stated that, “right after my retirement in 1993,” her debilitating condition “developed and quickly got worse leaving me unable to work or write for approximately three and a half years.”
By decision dated March 28, 1997, the Office hearing representative affirmed the Office’s November 12, 1996 decision.
By letter dated May 27, 1997, appellant requested reconsideration of the Office’s decision and submitted additional medical evidence. In her letter, appellant stated that by her statement in her February 21, 1997 letter, that her condition developed after she retired she meant to say that her condition developed to an unbearable point where extensive diagnosis and treatment was needed but prior to her retirement she had examinations and diagnoses of the problem as shown in attached medical reports. In nearly identical reports dated April 21 and May 21, 1997 respectively, Dr. Tetalman stated that, although appellant retired in October 1993, she complained of shoulder girdle/myofascial pain for at least a year prior to retirement. He stated:
“When the patient saw Dr. Frederick Crum, [a Board-certified family practitioner], he noted in his report of September 1993 that the patient had ‘an insidious onset of approximately one year ago of neck and shoulder pain, left greater than right. The patient states that this also developed in the hands, right greater than left and then her back….’ Also, in her medical files of the [employing establishment] which is dated July 7, 1993, it states that ‘yesterday the patient noted that her left wrist and arm were painful and swollen.’ ‘Left wrist and arm swollen; pulse normal; Phalen’s and Tinel’s test negative.… Cannot rule out carpal tunnel syndrome.”
In the May 21, 1997 report, Dr. Tetalman stated that, based on the determination of Dr. Crum and the Portsmouth Naval Shipyard Clinic, he believed that appellant’s problems of fibromyalgia/myofascial pain stemmed directly from appellant’s work at the employing establishment.
The progress notes from the employing establishment dated July 7, 1993 stated that appellant noted the previous day that her wrist and arm were painful and swollen, that she is right handed and worked on the computer. Further, carpal tunnel syndrome was diagnosed. The progress note also recorded that appellant’s left wrist and arm were swollen and carpal tunnel syndrome could not be ruled out. Dr. Crum referred appellant for physical therapy treatment at the Portsmouth General Hospital. In the initial physical therapy evaluation dated September 9, 1993, the report which is not signed, stated that appellant had myofascial pain syndrome and that appellant reported “an insidious onset of approximately one year ago of neck and shoulder pain, left greater than right and also developed this in the hands, right greater than left and then her back.” The report stated that appellant said that the pain in her hand increased with attempts to write and “report[ed] involvement with her ADL’s.” The report further stated that appellant had worked at a desk using a computer for over 20 years and that this appeared to play some role with this involvement.
By decision dated July 14, 1997, the Office denied appellant’s reconsideration request.
The Board finds that the Office properly found that appellant failed to establish that her fibromyalgia and myofascial pain in her neck, shoulder and right arm are causally related to factors of her federal employment.
To establish that an injury was sustained in the performance of duty, a claimant must submit the following: (1) medical evidence establishing the presence or existence of the condition for which compensation is claimed; (2) a factual statement identifying employment factors alleged to have caused or contributed to the condition; and (3) medical evidence establishing that the employment factors identified by the claimant were the proximate cause of the condition for which compensation is claimed or, stated differently, medical evidence establishing that the diagnosed condition is causally related to the employment factors identified by claimant. The medical evidence required to establish causal relationship, generally, is rationalized medical evidence. Rationalized medical opinion evidence is medical evidence, which includes a physician’s rationalized opinion on the issue of whether there is a causal relationship between the claimant’s diagnosed condition and the implicated employment factors. 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 factors identified by the claimant.[1]
In the present case, Dr. Tetalman’s cumulative opinion from his reports dated August 27 and December 9, 1996, April 21 and May 21, 1997 is that appellant’s fibromyalgia and myofascial pain arose from the repetitive motion of her using computers, cashiers and typewriters at work, from her posture in sitting at those machines and possibly from stress at work. Dr. Tetalman, however, did not provide a rationalized medical opinion as to how appellant’s fibromyalgia and myofascial pain arose from her employment. In his December 9, 1996 report, Dr. Tetalman noted that Dr. Crum’s September 9, 1993 report and the employing establishment’s July 7, 1993 medical records documented that within at least a year of her retirement appellant had pain and swelling in her left arm and wrist. Dr. Tetalman opined that appellant’s myofascial pain started “around the time, certainly before her retirement,” became progressive and appellant subsequently developed a secondary fibromyalgia. The record indicates that he first treated appellant in August 1996. Dr. Tetalman did not rationally explain what caused appellant’s conditions of myofascial pain and fibromyalgia to significantly worsen in the approximate three-year interval between her retirement and her seeking medical treatment. Further, although in his August 27, 1996 report Dr. Tetalman suggested that stress at work consisting of appellant having to meet deadlines contributed to her mysofascial pain, he did not explain the nature of the stress or how it specifically caused or contributed to her condition. Dr. Tetalman’s opinion is not sufficiently rationalized to establish the requisite causal relationship.[2] Appellant has, therefore, failed to establish her claim.
The decisions of the Office of Workers’ Compensation Programs dated July 14 and March 28, 1997 and November 12, 1996 are hereby affirmed.
Dated, Washington, D.C.
August 25, 1999
Willie T.C. Thomas
Alternate Member
Michael E. Groom
Alternate Member
A. Peter Kanjorski
Alternate Member