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Drinnin v. Colvin

United States District Court, E.D. Missouri, Eastern Division

January 9, 2015

LINDA K. DRINNIN, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

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[Copyrighted Material Omitted]

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For Linda K Drinnin, Plaintiff: Franklin A. Williams, DISABILITY LAW GROUP, LLC, St. Peters, MO.

For Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant: Jane Rund, LEAD ATTORNEY, OFFICE OF U.S. ATTORNEY, St. Louis, MO.

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This matter is before the Court for review of an adverse ruling by the Social Security Administration.

I. Procedural History

On October 2, 2006, plaintiff Linda Drinnin filed an application for disability insurance benefits, Title II, 42 U.S.C. § § 401 et seq., with an alleged onset date of February 24, 2005. (Tr. 78-83). She listed her disabling conditions as residual pain in her neck, right arm, and right hand following a neck fusion operation in 2005 and carpal tunnel syndrome. She stated that she was unable to work because the pain limited her ability to sit, stand, or walk for more than short periods of time, kept her from lifting anything heavy, and impaired her concentration and memory. (Tr. 107-15). After plaintiff's applications were denied on initial consideration (Tr. 47-53), she requested a hearing from an Administrative Law Judge (ALJ). (Tr. 4-5).

Plaintiff and counsel appeared for a hearing on January 24, 2008. (Tr. 23-42). The ALJ issued a decision denying plaintiff's applications on July 16, 2008. (Tr. 9-22). The Appeals Council denied plaintiff's request for review on December 3, 2010. (Tr. 1-3). Plaintiff sought review in this court, Drinnin v. Astrue, 4:11-CV-243 (CEJ), and on September 10, 2012, the court remanded the matter, based upon a determination that the ALJ improperly relied on the opinion of a non-medical source. [Doc. #16].

On October 15, 2012, the Appeals Council remanded the matter to the ALJ. (Tr. 397). The Council noted that plaintiff was found disabled as of August 1, 2009 -- based on a subsequent application filed on August 3, 2010 -- and instructed the ALJ to consider the additional evidence submitted with the subsequent claim. The Appeals Council noted that the ALJ might wish to obtain the testimony of a medical expert to address the issue of onset of disability prior to August 1, 2009.

Plaintiff and counsel appeared for a second hearing on February 6, 2013. (Tr.

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339-55). The ALJ again denied plaintiff's application in a decision issued on June 18, 2013. (Tr. 320-38). The ALJ's second decision stands as the final decision of the commissioner regarding disability prior to August 1, 2009.

II. Summary of Prior Medical Evidence

On February 25, 2005, plaintiff was admitted to St. Anthony's Medical Center with complaints of bilateral upper extremity numbness, tingling, pain, and weakness. She had been painting a wall when she felt weakness in her legs. She fell and hit her head. An MRI of the spine showed severe degenerative joint disease at C5-C6, osteophytes, disk complex impinging the anterior thecal sac, and significant neuroforaminal stenosis. The following day, Charles A. Wetherington, M.D., performed a cervical discectomy, nerve root decompression, and fusion at C4-C5, and C5-C6. (Tr. 166-67).

On March 8, 2005, plaintiff followed up with Dr. Wetherington. She appeared to be doing much better following her surgery, with good strength in her arms. However, she continued to have hyperpathic[1] pain in her hands that was reduced only with Darvocet[2] and Neurontin.[3] (Tr. 189). Plaintiff attended physical therapy in April and May 2005. After 12 sessions, she reported improvement in pain and range of motion but still experienced numbness, tingling, and sensitivity to ice and vibration. (Tr. 223).

On June 21, 2005, Dr. Wetherington noted that plaintiff's hyperpathic pain was limited to her middle fingers, but it continued to wax and wane. (Tr. 187). She also had " a fair amount of discomfort" in her neck. Her attempt to return to work failed due to decreased tactile sense in her hands. She continued to take 300 mg. of Neurontin, three times a day, and used 4 to 6 Darvocet each day. In September 2005, Dr. Wetherington noted that plaintiff's hyperpathic pain continued and opined that " carpal tunnel syndrome on top of her spinal cord injury [might be] diminishing her overall recovery of her central cord syndrome." (Tr. 186). A nerve conduction study showed findings consistent with bilateral mild carpal tunnel syndrome and a right C-7 nerve root lesion. (Tr. 140). In December 2005, Dr. Wetherington noted that plaintiff had increased neck discomfort and was having difficulty turning pages in a book and separating sheets of paper. (Tr. 184). CT scans showed the presence of a possible pseudarthrosis[4] at C5-C6, which Dr. Wetherington opined could be the cause of plaintiff's generalized neck pain. (Tr. 183). In April 2006, she continued to have some neck pain and worsening pain in her hands. (Tr. 182).

Dr. Wetherington performed a carpal tunnel release on plaintiff's right hand on July 5, 2006. (Tr. 155-56). On September 21, 2006, plaintiff told Dr. Wetherington that she had no improvement in her hand. (Tr. 181). She attended two scheduled physical therapy sessions. (Tr. 228-29). Despite good effort and a home treatment program, she reported no change in her symptoms and continued to experience

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tightness and sensitivity in her wrist and thumb. She showed some increase in strength in her right hand.

On October 2, 2006, plaintiff saw Chad Shelton, M.D., of Pain Management Services. She reported some improvement of her pain since undergoing carpal tunnel surgery in July 2006, but she still had significant allodynia[5] throughout her fingertips. Dr. Shelton administered a trigger point steroid injection to plaintiff's right wrist and gave her Lidoderm patches. (Tr. 191-95). On May 9, 2007, plaintiff returned to Dr. Shelton, complaining of constant moderate pain in her neck, hand, and arm. (Tr. 266-67). She told Dr. Shelton that the injection brought significant improvement in muscular pain in her hand, but she continued to have diffuse burning and tingling pain, with hyperesthesia,[6] allodynia, and occasional spasm. She had significant cold sensitivity and pain that radiated into her forearm with light touch. With respect to her neck, she had " some neck pain but [was] overall doing well from a surgical standpoint." Pain medications gave her some symptomatic control.

Plaintiff underwent pain management treatment with Nehalkumar Modh, M.D., from April 2008 through June 2008, for treatment of pain in her neck and arms, especially her right arm and hand. (Tr. 311-19). Dr. Modh noted the presence of allodynia and causalgia[7] in her right arm from her bicep to her fingertips, and decreased cervical range of motion. She reported minimal improvement with medications.

III. Additional Evidence Before the ALJ

A. 2010 Application Documents

Plaintiff completed a Function Report on September 4, 2010. (Tr. 513-24). She stated that she got up in the morning to help her son get ready for school. She then rested on the couch until her pain and dizziness subsided. She took a shower and, if she felt well enough, did light housework. She met her son's school bus in the afternoon, helped him with homework, and perhaps prepared a light meal in the microwave or crockpot. She no longer cooked family meals due to pain in her hands and dizziness upon standing. She could do light house work and some laundry, but her husband handled most household chores. She stated that she helped care for her son by getting out his clothes, getting his cereal, turning on his shower and tucking him into bed. She also helped him with his homework.

Plaintiff, who is right-hand dominant, explained that her ability to dress and manage her personal hygiene were affected by her inability to use her right hand. For instance, she avoided wearing tops with buttons or snaps and shoes that had to be tied. Due to her dizziness, she did not bathe unless someone was home. She was able to drive short distances of 10 to 15 miles alone and could shop for food and clothes. She had the mental, but not the physical, capacity to pay bills and manage bank accounts. She could not manage cash, however, because nerve damage made it hard for her to handle bills and coins and her pain medications made it

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hard for her to concentrate on counting. The only exercise she did was swimming. She visited at home with family members. She had difficulties with lifting, bending, standing, reaching, walking, sitting,[8] stair climbing, completing tasks, concentrating, remembering things, following instructions and using her hands. She explained that she could sit without head support for about 10 minutes. She experienced pain with standing, walking, and especially reaching. She could walk a block or less before she needed to rest for about 10 or 15 minutes. When she was pain-free, she could follow instructions very well, but she did not handle stress or changes in routine well.

B. February 6, 2013 Hearing Testimony

Plaintiff testified at the second hearing that she worked as a bank supervisor from 1987 until 2005. She left her job because she " woke up one day injured and . . . couldn't go to work" after " breaking her neck" while doing housework. (Tr. 343). She underwent cervical fusion in February 2005 and had carpal tunnel release surgery on her right arm in June 2007.

Plaintiff's husband Samuel Drinnin also testified. (Tr. 346-51). He stated that when plaintiff got up in the morning, she took her medications and, when she was able to, took a shower. She tried to make sure the children got off to school every day. She then rested for a while before trying to do housework, including sweeping, mopping, cleaning the bathroom, and laundry. On a good day, she could work for an hour before she needed to take a break. Three or four days a week, however, she was unable to do much more than rest. Mr. Drinnin testified that he left for work at 7:30 in the morning and came ...

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