JOHN D. EARLY, Magistrate Judge.
Plaintiff Victoria Lynn Murdock ("Plaintiff") filed a Complaint on August 1, 2017, seeking review of the denial of her application for Supplemental Security Income ("SSI") by the Commissioner of Social Security ("Commissioner" or "Defendant"). Dkt. No. 1. The parties filed consents to proceed before the undersigned Magistrate Judge. Dkt. Nos. 12, 13. In accordance with the Court's Order Re: Procedures in Social Security Appeal (Dkt. No. 10), on April 5, 2018, the parties filed a Joint Stipulation addressing their respective positions. Dkt. No. 22 ("Jt. Stip."). The Court has taken the Joint Stipulation under submission without oral argument and as such, this matter now is ready for decision.
On November 26, 2013, Plaintiff applied for SSI, alleging disability beginning on the same date. Administrative Record ("AR") 136-44. After her application was denied initially and upon reconsideration, Plaintiff requested an administrative hearing. AR 89-91. Plaintiff, represented by counsel, appeared and testified at a hearing before an Administrative Law Judge ("ALJ") on November 25, 2015. AR 38-69.
On December 24, 2015, the ALJ issued a decision finding Plaintiff was not disabled. AR 19-37. The ALJ determined that Plaintiff suffered from the following severe impairments: "right shoulder adhesive capsulitis, bilateral rotator cuff syndrome, bilateral carpal tunnel syndrome, lumbar spine strain/sprain, major depressive disorder, and anxiety disorder."
AR 27.
The ALJ found that Plaintiff was incapable of performing her past relevant work as a security guard (Dictionary of Occupational Titles ("DOT") 372.667-034). AR 32. However, the ALJ concluded Plaintiff was capable of performing other jobs that exist in significant numbers in the national economy, including: housekeeping cleaner (DOT 323.687-014); mail clerk (DOT 209.687-026); production line solderer (DOT 813.684-022). AR 33. The ALJ concluded that Plaintiff was not disabled from the alleged onset date through the date of the decision.
Plaintiff filed a request with the Appeals Council for review of the ALJ's decision. AR 133-35. On June 5, 2017, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the Commissioner's final decision. AR 1-7. This action followed.
Under 42 U.S.C. § 405(g), a district court may review a decision to deny benefits. The ALJ's findings should be upheld if they are free from legal error and supported by substantial evidence based on the record as a whole.
Lastly, even when the ALJ commits legal error, the Court upholds the decision where that error is harmless.
The parties present one disputed issue: Whether the ALJ properly considered the opinion of examining physician, Dr. Jonathan Kaplan ("Dr. Kaplan"), as set forth further below. Jt. Stip. at 4.
In assessing medical opinions, the ALJ must consider that there are three types of physicians who may offer opinions in Social Security cases: (1) those who directly treated the plaintiff, (2) those who examined but did not treat the plaintiff, and (3) those who did not treat or examine the plaintiff.
Although an ALJ is not required to discuss every piece of evidence or address every issue, he must explain why significant probative evidence has been rejected.
On February 22, 2014, Dr. Kaplan performed an orthopedic consultation. AR 292-99. Plaintiff described the following complaints at the examination: right shoulder pain; right elbow pain; bilateral wrist and hand pain; left knee pain; and lower back pain. AR 292. Dr. Kaplan diagnosed Plaintiff with the following: right shoulder adhesive capsulitis; bilateral carpal tunnel syndrome; and lumbar spine strain/sprain (mild in nature). AR 298. Dr. Kaplan concluded:
AR 298.
The ALJ summarized Dr. Kaplan's findings and conclusion in his decision. AR 30-31. The ALJ accorded partial weight to Dr. Kaplan's opinion providing that "subsequent MRI scans of the shoulders showing right shoulder partial tearing involving supraspinatus tendon" (citing AR 430, 501) and "left shoulder moderate acromioclavicular osteoarthrosis with findings suggesting external impingement" (citing AR 494) supported a limitation of occasional overhead reaching as opposed to frequent. AR 31.
Plaintiff argues that the ALJ erred in failing to take into account Dr. Kaplan's opinion in two specific respects: (1) that Plaintiff should continue the use of bilateral wrist splints for her carpal tunnel syndrome; and (2) that Plaintiff should continue to wear a sling to support her right upper extremity. Jt. Stip. at 7.
In response, the Commissioner argues that Dr. Kaplan did not opine, nor does the record indicate, that wrist splints or the use of a sling impeded Plaintiff's ability to perform work activity or constituted a basis for a work restriction. Jt. Stip. at 9-10. The Commissioner notes that, with respect to wrist splints, Plaintiff testified that she only used them "intermittently," admitting that she may go a week without using them, and the ALJ noted that Plaintiff did not use them at the hearing.
Replying to the Commissioner's arguments, Plaintiff asserts that the ALJ's "silence" with respect to Dr. Kaplan's opinion relating to the splints and the arm sling constitutes reversible error. Jt. Stip. at 12.
The Court finds that the ALJ's decision contains clear and convincing reasons that are supported by substantial evidence for not including an express limitation requiring the use of splints or an arm sling in Plaintiff's RFC.
As an initial matter, the Court notes that Dr. Kaplan's opinion does not state that splints or a sling are mandatory limitations; rather, Dr. Kaplan writes that Plaintiff "should continue to use" the splints and sling. AR 298. This is to be contrasted with the definitive language predominantly used by Dr. Kaplan regarding functionality, setting for precisely what Plaintiff "can," and by negative implication, cannot do.
Further, the ALJ's decision is not silent with respect to the splints or the underlying shoulder issues upon which the sling suggestion was based. The ALJ specifically recounted the two aspects of Dr. Kaplan's opinion at issue here — the wrist splints and right shoulder sling. AR 31. One paragraph removed from those references, the ALJ gave "partial weight" to Dr. Kaplan's opinion, noting subsequent MRI scans of the shoulders, but agreeing with Dr. Kaplan's assessment of light exertional work.
With respect to the splints, the ALJ specifically found that Plaintiff's own testimony showed she only used them "off and on," sometimes did not use them for a week at a time, did not wear them to the hearing, and testified that she had no trouble using a cell phone. Jt. Stip. at 29. This testimony provided clear and convincing reasons, supported by substantial evidence, for the ALJ's decision not to include a limitation in the RFC requiring Plaintiff to wear wrist splints, particularly in light of the fact that Dr. Kaplan merely recommended their use.
With respect to the issue of the right arm sling, Dr. Kaplan merely wrote, in February 2014, that a sling "should" be used "until [Plaintiff's] adhesive capsulitis [is] resolved." AR 298. In his decision, the ALJ expressly recounted the record that: (a) in May 2014 Plaintiff stated "her right shoulder was much better"; (b) in June 2014 Plaintiff described "she was doing much better with her right shoulder" and "could do everything much better with her right upper extremity"; (c) in July 2014, it was noted that Plaintiff's "right shoulder pain and range of motion improved with physical therapy"; and (d) in July 2014, when offered an injection, Plaintiff declined — all of which evidences rapid and significant improvement in Plaintiff's right shoulder after Dr. Kaplan's assessment. AR 28. By the time of the hearing, Plaintiff recounted that physical therapy "really helped me as far as the motion is concerned," had full range of motion in both shoulders, and could lift her right arm above her head without any pain. AR 50-52. Even to the extent Dr. Kaplan's statement that Plaintiff "should" use a right shoulder sling could be interpreted as a work-related recommended limitation, the recommendation was limited in time until the underlying issue resolved itself. The ALJ properly considered the medical evidence and Plaintiff's own testimony, including the apparent resolution of the limitation on her range of motion in her right shoulder, in formulating the RFC. To the extent that the ALJ's non-inclusion of the suggested, temporary right arm sling in Plaintiff's RFC can be considered an implicit rejection of a portion of Dr. Kaplan's opinion, the Court finds the ALJ's decision is based on clear and convincing reasons supported by substantial evidence.
The ALJ did not err in his consideration of Dr. Kaplan's opinion relating to wrist splints and a right shoulder sling in assessing Plaintiff's RFC. Further, to the extent Plaintiff's argument is that the ALJ erred in not specifically tying his findings regarding the splints and right shoulder to Dr. Kaplan's opinion that Plaintiff "should" use the splints and sling (
IT IS ORDERED that Judgment be entered affirming the decision of the Commissioner and dismissing this action with prejudice.