United States District Court, W.D. Missouri, Western Division
COREY L. SHERWOOD, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
NANETTE K. LAUGHREY, District Judge.
Plaintiff Corey Sherwood seeks review of the Administrative Law Judge's decision denying his application for Social Security benefits. For the following reasons, the decision of the Administrative Law Judge (ALJ) is reversed, and the case is remanded for the purpose of awarding benefits to Sherwood.
A. Medical History
Sherwood is forty-two years old with a high-school education. He has a learning disability, and was enrolled in special education classes for reading, writing, and math throughout much of school. He has previously worked as a sorter and laborer.
In April 2008, Sherwood began seeking medical treatment for back and knee pain. He saw Dr. Ronald Pak, who noted that Sherwood exhibited a "spastic gait quality" and had difficulty with single leg balance and decreased fine and gross motor coordination. Tr. at 500. Dr. Pak stated that Sherwood likely would not be able to function in a competitive work place. Tr. at 500. Sherwood also saw Ryan VanWinkle, MS, LPC. VanWinkle noted that Sherwood exhibited limited intellectual functioning, did not know the current month, and was unable to complete serial sevens without a number of mistakes. Tr. at 503. Throughout the rest of 2008 and 2009, Sherwood saw a series of doctors regarding his leg and knee pain and was prescribed a number of drugs for pain management, including Tramadol, Darvocet, and Naprosyn.
In November 2008, Sherwood saw Robert Forsyth, Ph.D., for a psychological consultation and intelligence testing. Sherwood exhibited lowered intellectual functioning. Tr. at 518. Dr. Forsyth noted that Sherwood could not name four presidents since 1950 and did not know the number of weeks in a year. Id. Dr. Forsyth stated that Sherwood's social judgment and abstract conceptual thinking skills were poor. Id. Dr. Forsyth gave Sherwood the Wechsler Adult Intelligence Scale test (WAIS-III), on which Sherwood achieved a verbal IQ score of 64, a performance IQ score of 78, and a full-scale IQ score of 67. Id. Dr. Forsyth diagnosed Sherwood with reactive mood disorder, learning disability, and substance abuse in remission, with borderline intellectual functioning. Tr. at 519.
In January 2009, Kenneth Burstin, Ph.D., completed a Psychiatric Review Technique and Mental Residual Functional Capacity Assessment on behalf of the state. Tr. at 526-540. He opined that Sherwood had borderline intellectual functioning and an anxiety disorder. Id. He stated that Sherwood would have marked limitations carrying out detailed instructions. Id. Despite these limitations, Dr. Burstin found that Sherwood could perform at least simple instructions and relate adequately to others in settings that do not require frequent public contact, and could adapt to non-complex changes. Tr. at 540.
In March 2009, Sherwood saw Diedra Hayman, Ph.D., for an initial psychological assessment. Dr. Hayman stated that Sherwood's insight and judgment were impaired due to his borderline intellectual functioning. Tr. at 564. She noted that his anxiety mainly centered on his physical health. Id.
In May 2009, Sherwood presented to OMC Orthopedics for evaluation of his knee pain. He stated that the pain in his knee had a stabbing quality. Tr. at 635. On exam, he had abnormal reflexes. Id. EGD and biopsy testing revealed esophagitis, chronic gastritis of the entire stomach, and bursitis. Tr. at 572, 579, 584. Later that month Sherwood was diagnosed with bilateral patellofemoral syndrome and bursitis. Tr. at 631. In September and October Sherwood reported some improvement in his knee pain with rehabilitation and physical therapy. By the end of October, his physical therapy had stopped providing any relief and Sherwood was diagnosed with chondrolamacia. Tr. at 629. In November he underwent a left knee arthroscopy and chondroplasty of the left femoral condyle. Tr. at 738-739. In December he received a shot of cortisone in his left knee. Tr. at 625.
Throughout 2010, Sherwood continued to attend regular appointments about his knee and refill his prescriptions for pain medication. In November 2010, Sherwood saw Dr. Michael Clarke for an orthopedic evaluation. Tr. at 721. Dr. Clarke noted tenderness to palpation of Sherwood's abdomen, but that his knees were stable. He further noted that Sherwood was "probably depressed." Tr. at 722.
In September 2011, James Spence, Ph.D., completed a Psychiatric Review Technique and Mental Residual Functional Capacity Assessment and reported that Sherwood had a learning disorder, borderline intellectual functioning, and reactive mood disorder. Tr. at 687-688. He stated that Sherwood would be capable of simple, routine tasks. Id.
In June 2012, Dr. Michael Ball completed a Mental Residual Functional Capacity Assessment and reported that Sherwood was limited in what he could lift, the amount of time he could stand and sit, and could never climb, crouch, kneel, or crawl. Tr. at 774-775. He also stated that Sherwood would have marked limitations completing a normal work day or work week without interruption from psychologically-based symptoms, and be limited in his ability to perform at a consistent pace without an unreasonable number of rest periods. Tr. at 777-778.
In September 2012, Dr. Herschel Goren completed medical interrogatories at the request of the ALJ. Tr. at 743-750. Dr. Goren concluded that Sherwood met Listing 12.05(c) as of November 19, 2008. Tr. at 760. He noted that Sherwood had ...