SHON T. ERWIN, Magistrate Judge.
Plaintiff brings this action pursuant to 42 U.S.C. § 405(g) seeking judicial review of Defendant Commissioner's final decision denying Plaintiff's applications for benefits under the Social Security Act. This matter was referred for hearing, if necessary, and for the submission of findings and recommendations pursuant to 28 U.S.C. §§ 636(b)(1)(B), 636(b)(3), and Fed. R. Civ. P. 72(b). The administrative record (Tr.)
A court reviews the Commissioner's decision to determine whether the factual findings are supported by substantial evidence and whether the correct legal standards were applied. Mays v. Colvin, 739 F.3d 569, 571 (10
In a decision issued on December 6, 2011, the administrative law judge (ALJ) found that Plaintiff
(Tr. 17). Based on this RFC, the ALJ found that Plaintiff could not perform any of her past relevant work: heavy equipment operator in the Army, prep cook, gymnastics coach, roofer, and telemarketer. (Tr. 24).
However, at step five, the ALJ found that Plaintiff could perform other jobs existing in the national economy. (Tr. 24-25). In reaching this finding, the ALJ relied on the testimony of a vocational expert (VE) and, as a framework, the Medical-Vocational Guidelines, 20 C.F.R. Part 404, Subpart P, Appendix 2. Id. The VE identified the following representative jobs that a person with Plaintiff's RFC and vocational factors` could perform: assembler, press operator/laundry machine operator, and maid/housekeeper. (Tr. 25). Thus, at step five of the sequential analysis, the ALJ found that Plaintiff was not disabled and therefore not entitled to benefits. (Tr. 25).
In this appeal, Plaintiff alleges four errors.
In support of her first claim of error, Plaintiff claims that substantial evidence shows she cannot engage in prolonged standing and walking. (Plaintiff's Br., ECF No. 23:7). She argues that x-rays confirmed a tibial plateau stress fracture in 2007, (Tr. 247), and that beginning in 2009, medical providers suspected a meniscus tear of the left knee and injury to the plica band of the left knee. (Plaintiff's Br., ECF No. 23:7).
In response, the Commissioner argues that many of Plaintiff's contentions depend on the ALJ's finding as to her credibility, a finding she has not challenged in this appeal. (Brief in Support of the Commissioner's Decision, 4) (hereinafter Commissioner's Br., ECF No. 24:4). The Commissioner further contends that Plaintiff's claims relating to her knee function are based upon a misreading of her x-rays, which showed no abnormalities. (Commissioner's Br., ECF No. 24:4) (citing Tr. 375-77, 455, 459). The Commissioner noted state agency consultant Dr. Baldwin's question as to the "accuracy" of consultative physician Dr. Quadeer's diagnosis of left knee pain due to a stress fracture of the "plica," arguing that the plica could not be seen on an x-ray nor could it be subject to a stress fracture. (Commissioner's Br., ECF No. 24:5) (citing Tr. 405, 446). Thus, the Commissioner argues that no "diagnostic testing" existed to support a cause of Plaintiff's claimed knee discomfort in December 2010. (Commissioner's Br., ECF No. 24:5).
The undersigned finds that the ALJ's decision regarding the effect of Plaintiff's left knee pain is not supported by substantial evidence. Beginning in June of 2009, ANRP Wendy Gaston noted that Plaintiff's range of motion in her left knee was limited by pain. (Tr. 460). Later that same month, Dr. Cheyne found her left knee to be tender and suspected a meniscus tear. (Tr. 375). However, he stated that he needed an MRI to confirm his assessment; a little over a month later, he noted that the MRI had still not been approved. (Tr. 374-75). At that time, he found Plaintiff to be in "very significant pain", and prescribed Mobic and Darvocet. (Tr. 374). Plaintiff was seen in the emergency room on July 12, 2009, where it was again recommended that Plaintiff have an MRI. (Tr. 273). Plaintiff was directed to follow up with Dr. Cheyne "ASAP," and ibuprofen was prescribed. (Tr. 273). In August 2009, Reserve Health Readiness Services conducted a Periodic Health Assessment finding that Plaintiff could stand no more than two hours due to her knee pain. (Tr. 379). It was found that Plaintiff did not meet retention standards due to depression, knee pain, and low back pain. (Tr. 378-79). In November 2009, an MRI was again ordered but not completed. (Tr. 392). On December 14, 2009, Plaintiff was medically discharged from the Army Reserve. (Tr. 140).
In October 2010—over a year after Plaintiff first sought treatment for her knee pain—Plaintiff was seen at the Stigler Health and Wellness Center by nurse practitioner Conaway; Plaintiff's left knee—in particular her MCL and LCL—were found to be tender to palpation, and there was extreme laxity of her MCL. (Tr. 450). An MRI was recommended, but Plaintiff stated she had no way to pay for it. She was prescribed Meloxicam. (Tr. 451). Plaintiff was seen for follow up at the Stigler Health and Wellness Center in November 2010; Tracy Baker, M.D., found Plaintiff's knee to be moderately tender, there was slight effusion, and the medial joint bulged when pressed. (Tr. 453). Plaintiff was prescribed Voltaren, and was given a Kenalog injection in her left knee. (Tr. 453).
In December 2010, consultative examiner Mohammed Quadeer, M.D., found that movements of Plaintiff's left knee were "associated with pain with full range of motion." (Tr. 405). There was no effusion or edema at that time, and her knee was stable in all range of motion exercises. (Tr. 405). Dr. Quadeer assessed pain in the left knee due to a stress fracture on June 21, 2007. (Tr. 405). However, Dr. Quadeer referenced a stress fracture to the "plica" rather than the "tibia." (Tr. 405). His examination showed knee flexion to be limited to 100/150 degrees, secondary to pain. (Tr. 407).
State medical consultant Donald Baldwin, M.D., limited Plaintiff to light work, opining that she could stand about six of eight hours. (Tr. 440). He also found that she could only stoop occasionally. (Tr. 441). His comments referenced that no "additional" MRI had been performed, and that Plaintiff continued to have pain in her left knee. (Tr. 440). He failed to mention Plaintiff's attempts to get an MRI approved while still in the Army Reserve, and her inability to pay for that diagnostic test after discharge. (Tr. 440-41). He also failed to mention that Plaintiff received treatment for a soft tissue injury despite the MRI. (Tr. 440-41). He also noted Dr. Quadeer's reference to a "stress fracture of the plica," apparently disregarding his other findings because of this despite the MRI. (Tr. 440-41). He also noted Dr. Quadeer's reference to a "stress fracture of the plica," apparently disregarding his other findings because of this mistake/typographical error, and concluding that knee pain was not present "due" to Dr. Quadeer's diagnosis. (Tr. 446). The state agency medical consultant also stated that "[i]t is noted that no other physical sighs [sic] and no symptoms support the diagnosis of a meniscus tear." (Tr. 446). He referenced a single examination on June 16, 2009, but ignored physical signs found during examinations in October and November of 2010, in which Plaintiff's MCL and LCL were found to be tender to palpation; there was extreme laxity of her MCL; her knee was moderately tender; there was slight effusion; and the medial joint bulged when pressed. (Tr. 450-54). It is not clear whether the state agency consultant was unaware of these records, or just failed to find them relevant for some reason.
In the physical health assessment dated one month after Plaintiff presented with knee pain, Dr. Paparo noted that Plaintiff was unable to run two miles, and was only unlimited in walking if at her own pace and distance. (Tr. 379). She was noted to be unable to stand more than two hours. (Tr. 379). Although the Commissioner claims that this shows no "obvious conflict with the demands of light work" (Commissioner's Br., ECF No. 24:7) (citing SSR 83-10), the Commissioner is clearly incorrect in that light work requires standing for up to six hours in an eight hour day. See SSR 83-10, 1983 WL 31251 (many light jobs performed primarily in one location, with ability to stand being more critical than ability to walk).
It may be that the ALJ's finding regarding Plaintiff's ability to stand was based on his opinion that "normal breaks" would have accommodated Plaintiff's inability to stand for more than two hours—but such would be surmise on the undersigned's part. The the occupational base. At step five, the burden of proof is on the Commissioner to show that Plaintiff can perform other work. Williams v. Bowen, 844 F.2d 748, 751 (10
"An ALJ must evaluate every medical opinion in the record, although the weight given each opinion will vary according to the relationship between the disability claimant and the medical professional.... An ALJ must also consider a series of specific factors in determining what weight to give any medical opinion." Hamlin v. Barnhart, 365 F.3d 1208, 1215 (10
In light of this error, it is unnecessary to discuss Plaintiff's other claims of error. However, upon remand, the Commissioner is urged to carefully consider those arguments and more thoroughly evaluate Plaintiff's alleged mental impairments under the applicable standards, and consider whether the ALJ should have found Plaintiff's headaches to be nonsevere.
Having reviewed the evidence of record, the transcript of the administrative hearing, the decision of the ALJ, and the pleadings and briefs of the parties, the undersigned magistrate judge finds that the decision of the Commissioner should be
The parties are advised of their right to file specific written objections to this Report and Recommendation. 28 U.S.C. § 636 and Fed. R. Civ. P. 72. Any such objections should be filed with the Clerk of the District Court by
This Report and Recommendation terminates the referral by the District Judge in this matter.