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Andreatta v. Colvin

United States District Court, W.D. Missouri, Southern Division

July 10, 2015

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


NANETTE K. LAUGHREY, District Judge.

Plaintiff Mary A. Andreatta appeals the Commissioner of Social Security's final decision denying her application for disability insurance benefits under Title II of the Social Security Act. The decision is affirmed.

I. Background

Andreatta was born in 1960. She filed her application for disability insurance benefits in March 2008, alleging she became disabled beginning February 7, 2008, due to diabetes mellitus with neuropathy. The Administrative Law Judge held a hearing on November 6, 2009 and denied Andreatta's application on March 10, 2010. The Appeals Council denied her request for review in March 2011, but in May 2012, this Court reversed and remanded for consideration of post-hearing evidence submitted by Andreatta.

The ALJ held a second hearing on the application in August 2013, and issued a decision in September 2013, again denying Andreatta's application. The Appeals Council denied Andreatta's request for review in October 2014.[1] Thus, the relevant alleged disability period for purpose of the present appeal is February 7, 2008 through the date of the ALJ's first decision, March 5, 2010.

In this appeal, Andreatta focuses on certain of the severe impairments reflected in the September 2013 decision-neuropathy, degenerative joint disease of the right shoulder, and carpal tunnel syndrome-and how they affect the RFC determination.

A. Medical history

1. Dennis E. Robinson, D.O.

Dr. Robinson, Andreatta's primary care doctor, assessed bilateral carpal tunnel syndrome in March 2005, after a nerve conduction study was positive for moderate neuropathy on the right and left. He recommended conservative treatment.

In February 2006, Dr. Robinson noted tenderness in Andreatta's lumbar spine, reduced flexion and extension, and muscle spasm, but negative straight leg test. Andreatta had normal range of motion and no tenderness or swelling in her upper and lower extremities. Medication was prescribed. In June 2006, Dr. Robinson examined Andreatta's back and extremities and observed no abnormalities. In July 2006, examination indicated increased sensitivity in Andreatta's lower legs consistent with neuropathy, but she refused an appointment with a neurologist. In September 2006, Andreatta's upper and lower extremities exhibited no abnormalities.

In November 2007, Dr. Robinson diagnosed a sprain or strain of the right shoulder, and gave Andreatta an injection. In December 2007, Andreatta complained she could "hardly work" due to right arm pain. Dr. Robinson diagnosed neuropathy, and noted a reduced range of motion in the right shoulder, which he injected with lidocaine.

In January 2008, Dr. Robinson noted normal range of motion, with no joint tenderness or swelling in the lower or upper extremities. Dr. Robinson stated in a letter dated January 30, 2008, that Andreatta had diabetes mellitus and diabetic neuropathy with frequent episodes of pain. In February 2008, Andreatta saw Dr. Robinson for complaints of pain in her right arm and legs. Examination indicated Andreatta's right arm was tender, with decreased range of motion, but revealed no evidence of lower extremity abnormalities. The doctor assessed diabetic neuropathy and prescribed medications. In March 2008, Andreatta complained of "lower back pain and spasm, lots of neuropathic pain in the legs and feet.[]" [Tr. 219.] Dr. Robinson did not record objective findings. His assessment was diabetic neuropathy, lower back pain, and uncontrolled diabetes, and medication was prescribed.

Andreatta saw Dr. Robinson in June 2008, following up on her recent hospitalization for diabetic ketoacidosis. The doctor noted Andreatta was "doing better." [Tr. 309.] In July 2008, Dr. Robinson found no abnormalities of the upper or lower extremities on examination. In August 2008, Dr. Robinson noted Andreatta's right shoulder had reduced range of motion, but was not tender. Her right forearm was tender. Medications were prescribed. Andreatta reported neuropathic pain to Dr. Robinson in September 2008, but the doctor noted no abnormalities on examination. In October 2008, Dr. Robinson noted Andreatta had neuropathic pain in her legs and feet, right shoulder tenderness with crepitus, and hand pain. Medications were prescribed and Andreatta was given an injection.

A nerve conduction study on October 22, 2008, indicated carpal tunnel syndrome. Dr. Robinson noted on October 27, 2008, that Andreatta's hands were tender. In November 2008, Dr. Robinson assessed uncomplicated diabetes, neuropathy, and carpal tunnel syndrome. Objective examination findings were normal. Andreatta saw Dr. Robinson for sinus problems and congestion in December 2008, and he noted normal range of motion and no tenderness or swelling of her upper or lower extremities.

In January 2009, Dr. Robinson diagnosed shoulder problems. Examination showed full range of motion with slight tenderness to deep palpation in the anterior shoulder and discomfort with resistance. Medications were prescribed. In March 2009, Dr. Robinson assessed diabetic neuropathy and uncomplicated diabetes. Examination indicated decreased sensation in both feet, and some fungus on the nails, but was otherwise normal. Medications were prescribed. In April 2009, Dr. Robinson assessed abdominal pain and neuropathy, but noted no objective findings. In May 2009, Dr. Robinson assessed neuropathy, fibromyositis, and low back pain. Physical examination was normal. Medications were prescribed. In June 2009, Dr. Robinson's assessment was unchanged, and he noted no objective medical findings.

In October 2009, Andreatta saw Dr. Robinson for emergency room follow up, complaining of back and extremity pain. Andreatta exhibited restricted range of motion, pain, muscle spasms, and point tenderness in her lumbar spine, and pain, tenderness, and muscle spasms in the thoracic region. A straight leg test was negative. Dr. Robinson noted neuropathy in both hands, with decreased sensation and strength bilaterally. He assessed diabetic neuropathy, low back pain, and irritable bowel syndrome. At a December 2009 visit, Dr. Robinson assessed fibromyositis and irritable bowel syndrome, noting no abnormalities, normal range of motion, no joint tenderness, and no swelling of the upper or lower extremities.

Andreatta saw Dr. Robinson in January 2010 for medication refills and with complaints of congestion and left hip pain. The doctor assessed Eustachian tube dysfunction and uncomplicated diabetes, and noted no abnormalities on exam. In March 2010, Andreatta complained of a sore throat, sinus congestion, and left knee pain. Dr. Robinson assessed acute pharyngitis, knee effusion, and palpitations. Andreatta's left knee was tender, with reduced range of motion, but her upper extremities and neck were normal.

2. Specialists

Andreatta was seen at St. John's Clinic on November 25, 2008, for problems with her hands going numb. On December 31, 2008, Victoria D. Kubik, M.D. performed bilateral carpel tunnel release surgery. Andreatta saw Dr. Kubik for follow up on January 13, 2009, stating that the numbness and tingling had significantly improved, though she still had unexpected soreness in the wrist and hands. Dr. Kubik noted that the soreness was expected after a bilateral carpal tunnel release.

Andreatta went to St. John's Clinic on January 25, 2009, for an evaluation of her right shoulder. An x-ray showed significant degenerative changes of her acromioclavicular joint with spurring. On January 30, 2009, Victor Wilson, M.D., performed right shoulder arthroscopic surgery, with debridement of the superior labrum, subacromial decompression, and distal clavicle excision. On March 2, 2009, Dr. Wilson opined that Andreatta was doing well and had full passive and active range of motion. [Tr. 322.]

Dr. Robinson referred Andreatta to Jennifer Zhai, M.D., a neurologist, for consultation concerning Andreatta's neuropathy. Andreatta saw Dr. Zhai on May 14, 2009, and explained Neurontin helped initially, but lost its efficacy; Cymbalta caused a significant cognitive side effect; and Lyrica helped her pain, but she could not tolerate a higher dosage. Examination revealed reflexes at 2/5 at bilateral biceps, triceps, brachioradialis, and absent at the knees and ankles. Examination also showed a decrease in pinprick and light touch in the lower extremities in stocking distribution. Dr. Zhai diagnosed diabetic neuropathy and chronic pain syndrome.

Andreatta saw Dr. Zhai again on September 23, 2009, complaining of a year-long tremor in the right arm and two-month tremor in the left arm. Andreatta said the tremors increased with activity, were intermittent, and sometimes affected her ability to do fine motor activities. She also said she continued to have chronic pain. Examination revealed a tremor in both arms and hands, more on the right side on extension. Dr. Zhai diagnosed tremor, diabetic neuropathy, and chronic pain syndrome that was probably multifactorial. The doctor believed the tremor was due to Andreatta's inhaler.

On August 2, 2010, Andreatta returned to Dr. Wilson with complaints about her right shoulder. Although Andreatta "did great" with her arthroscopy a year and a half earlier, over the previous few weeks she had gradually increasing pain. [Tr. 425.] She said the pain worsened with overhead activities and improved with rest. Dr. Wilson diagnosed status post right shoulder arthroscopy with a recent flare-up and signs of rotator cuff tendinitis, and fibromyalgia, and gave Andreatta an injection.

Andreatta saw Dr. Evenson on August 23, 2010, with complaints of back pain lasting three years. Examination revealed tenderness throughout the lumbar spine. Dr. Evenson noted that an MRI showed small spondylolisthesis darkening in the L5-S1 disc. He also noted Andreatta had a slow gait, she rose from a seated position very stiffly, she had limited range of motion of her lumbar spine secondary to discomfort, there was pain to palpation in the midline in the lower lumbar region, and pain to palpation in the facet and sacroiliac joints. He diagnosed chronic pain, chronic lower back pain probably secondary to spondylolisthesis, fibromyalgia, and tobacco abuse. On ...

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