U. S. DEPARTMENT OF LABOR
Employees’ Compensation Appeals Board
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In the Matter of DARLENE D. ROLLING and U.S. POSTAL SERVICE,
POST OFFICE, Oakland Park, FL
Docket No. 99-154; Submitted on the Record;
Issued September 1, 2000
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DECISION and ORDER
Before MICHAEL J. WALSH, DAVID S. GERSON,
VALERIE D. EVANS-HARRELL
The issue is whether appellant has met her burden of proof in establishing that she sustained a recurrence of disability on June 25, 1997 causally related to her August 18, 1994 accepted employment injury.
On August 23, 1994 appellant, then a 38-year-old letter carrier, filed a claim for traumatic injury alleging that on August 18, 1994 she tripped and fell while in the performance of duty and sustained injuries to her chest wall and right shoulder.
On March 23, 1995 the Office of Workers’ Compensation Programs accepted appellant’s claim for chest contusion and right shoulder strain.
On September 17, 1997 appellant filed a claim for recurrence of disability commencing June 25, 1997 alleging that her work-related injury was ongoing and that she did not “have full use of her right arm, still having pain and discomfort when using arm, tightness in the neck, right arm, back of shoulder.” She noted in a box on her claim form that she was off work following her recurrence from June 25 to September 17, 1997.
By letter dated February 9, 1998, the Office advised appellant to submit additional information regarding her recurrence of disability claim, including a detailed narrative medical report explaining how her doctor believed that her current medical condition was causally related to the August 18, 1994 work-related injury.
By decision dated March 13, 1998, the Office denied appellant’s claim on the grounds that the medical evidence failed to establish that her medical condition was causally related to her August 18, 1994 employment injury.
By letter dated April 8, 1998, appellant requested reconsideration. By merit decision dated April 28, 1998, the Office denied appellant’s request for modification.
The Board finds that appellant has failed to meet her burden of proof in establishing that she sustained a recurrence of disability on or about June 25, 1997 causally related to her August 18, 1994 employment injury.
Appellant has the burden of establishing by the weight of the substantial, reliable and probative evidence, a causal relationship between her recurrence of disability commencing on or after June 25, 1997 and her August 18, 1994 employment injury.[1] This burden includes the necessity of furnishing medical evidence from a physician who, on the basis of a complete and accurate factual and medical history, concludes that the disabling condition is causally related to employment factors and supports that conclusion with sound medical reasoning.[2]
In support of her claim, appellant submitted medical reports from Dr. Melvyn H. Rech, her treating osteopath. He stated in a September 9, 1997 medical report that appellant related a June 26, 1997 incident at home when she experienced pain in her right shoulder while reaching under her bed.[3] Dr. Rech found that appellant had sustained adhesive capsulitis of the right shoulder, concluding that there was a “possibility that this may be industrially related.” In a medical report dated October 6, 1997, he stated:
“[Appellant] had sustained an industrial[-]related injury to the right shoulder in 1994.
“From what I understand, [appellant] had experienced pain and restricted motion which became progressive. Subsequently as noted on my consultation, she was reached (sic) out of bed to get a heating pad to alleviate this problem when she experienced an acute exacerbation of this pain.”
“Therefore, it is noted that [appellant’s] injury at this time is related to the 1994 incident.”
Appellant also submitted a March 12, 1998 treatment note from Dr. Rech in which he stated that appellant’s back pain injury occurred when she was beginning to bend over from a standing position. These reports are not sufficient to meet appellant’s burden of proof as Dr. Rech did not provide any medical rationale in support of his opinion regarding the causal relationship between appellant’s current condition and her accepted employment injuries. He did not describe the injuries that appellant sustained on August 18, 1994 and did not offer any medical reasoning explaining how these injuries could result in a recurrence of disability in June 1997.
Further, the record also reveals that appellant’s treating physician, Dr. Michael A. Kelly, Board-certified in orthopedic surgery, in a medical report dated November 14, 1994, stated that appellant’s cervical strain had resolved and he recommended that she “return to full duty without restrictions.” He noted that he had examined appellant that day in a follow-up examination for cervical strain. Dr. Kelly noted that appellant’s range of motion was “80 degrees of flexion, 80 degrees of extension, full lateral rotation right and left and full lateral bending, right and left. [Appellant’s] reflexes are two plus and equal bilaterally. [She] is five by five in all motor groups in the upper extremities from the trapezius to the intrinsics.”
Appellant also submitted multiple treatment notes and medical records relating various medical conditions, none of which were accepted by the Office and are, therefore, insufficient to meet her burden of proof.
As appellant failed to submit rationalized medical opinion evidence establishing a causal relationship between her current condition and her accepted employment injury, she failed to meet her burden of proof and the Office properly denied her claim.
The decisions of the Office of Workers’ Compensation Programs dated March 13 and April 28, 1998 are hereby affirmed.
Dated, Washington, D.C.
September 1, 2000
Michael J. Walsh
Chairman
David S. Gerson
Member
Valerie D. Evans-Harrell
Alternate Member