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Herren v. Colvin

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

October 5, 2016

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


          John M. Bodenhausen United States Magistrate Judge

         This action is before the Court, pursuant to the Social Security Act (“the Act”), 42 U.S.C. §§ 401, et seq. The Act authorizes judicial review of the final decision of the Commissioner of Social Security (the “Commissioner”) denying Plaintiff Thresa Mae Herren's application for Disability Insurance Benefits. All matters are pending before the undersigned United States Magistrate Judge with consent of the parties, pursuant to 28 U.S.C. § 636(c). The matter is fully briefed, and for the reasons discussed below, the Commissioner's decision is affirmed.

         Procedural History & Summary of Memorandum Decision

         On January 31, 2013, Plaintiff filed an application for Disability Insurance Benefits (“DIB”) under Title II of the Act. Plaintiff alleged a disability onset date of September 30, 2011. (Tr. 16)[1] Plaintiff's claim was denied initially on March 26, 2013. (Id.) Thereafter, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”), which was held on April 22, 2014. Plaintiff and Janice Hastert, an independent Vocational Expert (“VE”), testified at the hearing. (Tr. 29) On May 20, 2014, the ALJ issued a decision concluding that Plaintiff was not disabled under the Act. (Tr. 16-25) The Social Security Administration Appeals Council denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner in this matter. (Tr. 1) Plaintiff filed the instant action on October 28, 2015. (ECF No. 1) Accordingly, Plaintiff has exhausted her administrative remedies and the matter is properly before this Court. Plaintiff has been represented throughout all relevant proceedings.

         Although the ultimate issue before the Court is whether substantial evidence supports the Commissioner's decision, Plaintiff's request for judicial review asks the Court to consider two issues, namely:

(1) Whether the ALJ erred in resolving alleged inconsistencies among three source opinions, and consequently, whether the ALJ's determination of Plaintiff's Residual Functional Capacity (“RFC”) was supported by substantial evidence; and
(2) Whether the ALJ erred in assessing Plaintiff's credibility.

         After a thorough review of the record, the Court concludes that the Commissioner's decision is supported by substantial evidence. The differences between the source opinions were adequately explained by the ALJ's decision. The ALJ's determination of Plaintiff's RFC is supported by the record and the ALJ's decision fairly articulates a basis for that RFC. The ALJ properly evaluated Plaintiff's credibility and adequately explained the bases for finding Plaintiff's subjective allegations less than fully credible.

         Administrative Record[2]

         I. General

         At the time of her administrative hearing, Plaintiff was 51 years old. Prior to 2013, Plaintiff had a fairly robust work history, having previously worked as a janitor and machine operator. (Tr. 178, 221) Plaintiff represents that she has been disabled since September 30, 2011, when she injured her knee while “she was going down some stairs with a bucket and … missed a step.” (Tr. 239)

         Plaintiff claims she is disabled due to mobility problems, mostly related to problems with her left knee. Plaintiff also reported left arm numbness and a pinched nerve in her neck. (Tr. 166) According to Plaintiff, her injuries prevent her from standing or sitting for long periods of time. (Tr. 173) Plaintiff's 2011 knee injury resulted in two knee surgeries-the first in December 2011 and the second in August 2012. Plaintiff returned to work after each surgery, but was laid off in 2013. (Tr. 163)

         In her Function Report - Adult, Plaintiff listed the following conditions that impact her ability to work: lifting, squatting, bending, standing, walking, sitting, kneeling, and stair climbing. (Tr. 199) Plaintiff represented that “stair climbing puts pressure on my knee and it hurt[s]. I can only lift about 20 pound[s], and squatting, bending, standing, [or] kneeling makes my knee hurt. Walking about 1 hour makes my knee swell up and I have to ice it down. Sitting about 1 hour make[s] my knee start hurting [and I] have to raise [my] knee up on pillows and ice [it] down.” (Id.)

         II. Medical and Opinion Evidence

         A. Dr. James Edwards, M.D.

         As noted above, Plaintiff's principle impairment relates to a left knee injury. Plaintiff's treating physician for her knee injury was Dr. James Edwards, M.D. Because Dr. Edwards' treatment of Plaintiff and his opinions regarding her abilities are significant considerations in this case, the undersigned will summarize Dr. Edwards' treatment records in detail to provide greater context to the Court's decision.

         The record indicates that, although Plaintiff injured her knee on September 30, 2011, her first visit with Dr. Edwards was on November 7, 2011. (Tr. 239) Plaintiff reported that she missed a step while she was going down stairs with a bucket. (Id.) Plaintiff had a twist injury, with most of her pain on the medial (inside) part of her left knee, with a little pain in the anterior (front) and posterior (back) portions as well. (Id.) X-ray images of Plaintiff's knee showed “a relatively well aligned joint with no obvious or acute abnormalities, ” with “[w]ell maintained joint space.” (Id.) Dr. Edwards ordered an MRI to rule out a medial meniscal tear, and recommended no squatting or kneeling. (Tr. 240) Dr. Edwards indicated that Plaintiff could return to work, but was limited to no bending, squatting, twisting, or kneeling. (Tr. 279)

         Plaintiff had an MRI of her left knee on November 21, 2011 (Tr. 241), and a follow-up visit with Dr. Edwards on November 28, 2011. At the follow-up, Plaintiff complained of pain. Dr. Edwards's clinical impression was a “high suspicion for a medial meniscal tear, ” and that Plaintiff “[m]ay have a component of lateral patella compression syndrome.” (Tr. 242) As a result, on December 15, 2011, Dr. Edwards performed arthroscopic lateral release surgery on Plaintiff's left knee cartilage. (Tr. 237-38, 244) Dr. Edwards indicated that Plaintiff could return to work, but she was limited to no bending, squatting, twisting, or kneeling. (Tr. 280)

         On December 28, 2011, in Plaintiff's first follow-up visit after her knee surgery, Dr. Edwards noted that Plaintiff needed therapy twice per week for two weeks, and that she did not require any pain medication. (Tr. 245)[3] During a follow-up appointment on January 17, 2012, Dr. Edwards noted that, “[o]verall she is doing very well.” Plaintiff was continued on physical therapy, and allowed to return to work with restrictions of “no kneeling, squatting, or ladder climbing.” (Tr. 246, 282)

         Plaintiff returned to Dr. Edwards on January 30, 2012, after she “felt a pop.” (Tr. 248) Plaintiff was given a corticosteroid (Depomedrol) injection and continued on therapy. Dr. Edwards continued the work-related restrictions of no kneeling, squatting, twisting, or ladder climbing, and added a lifting restriction of not greater than five pounds. Dr. Edwards specifically instructed that Plaintiff should not lift mop buckets. (Tr. 248, 283)

         Plaintiff's next follow-up visit with Dr. Edwards was on February 21, 2012. Dr. Edwards was concerned that Plaintiff's symptoms were greater than he would like to see at that point. (Tr. 250) As a result, Dr. Edwards administered another corticosteroid injection. Plaintiff's therapy was discontinued but her work restrictions were to remain in effect. Dr. Edwards began a course of treatment using Naprosyn (an NSAID anti-inflammatory drug). (Id.) During follow-up treatment on March 5, 2012, Dr. Edwards noted that Plaintiff continued to complain of symptoms “when she is up.” Dr. Edwards continued Plaintiff's work restrictions, and returned her to physical therapy. (Tr. 251) Plaintiff returned to Dr. Edwards on March 26, 2012, still complaining of pain. (Tr. 252) Dr. Edwards discontinued therapy, continued Plaintiff's work-related restrictions, ordered another MRI, and ordered a brace. (Id.)

         Plaintiff had another MRI of her left knee on April 11, 2012, and a follow-up visit with Dr. Edwards on April 23, 2012. (Tr. 254, 256) Dr. Edwards noted no evidence of any meniscal pathology but some evidence of fibrosis. (Tr. 224-25) As a result, Plaintiff elected to have Dr. Edwards perform an arthroscopic debridement procedure on her left knee. (Tr. 256) In the meantime, Plaintiff received pain medication and her work-related restrictions remained in place. (Tr. 256-67, 286-89)

         On August 9, 2012, Dr. Edwards performed an arthroscopic “major debridement” procedure on Plaintiff's left knee. (Tr. 231-32, 268) During a follow-up visit on August 22, 2012, Plaintiff was “doing fairly well, ” but was “non weight bearing.” Plaintiff was working on her range of motion and continued on the same work restrictions “as far a sedentary only.” (Tr. 270, 290) During follow-up treatment on September 12, 2012, Dr. Edwards noted that Plaintiff continued to “have some discomfort with extremes.” (Tr. 272) Dr. Edwards recommended Plaintiff be “fairly aggressive” going forward with exercise therapy, with four weeks of therapy, three-to-five times per week. (Id.) Dr. Edwards continued Plaintiff's work-related restrictions, including limiting her to sedentary work. (Tr. 272, 291) During follow-up treatment on September 26, 2012, Dr. Edwards noted that Plaintiff was “getting some improvement” but she also continued to have difficulty and discomfort. Dr. Edwards continued Plaintiff's therapy and sedentary work-related restrictions. (Tr. 274, 292)

         On November 6, 2012, Plaintiff returned to Dr. Edwards for a follow-up appointment. At that time, Dr. Edwards noted that Plaintiff was “[d]efinitely improving.” Dr. Edwards limited Plaintiff's physical therapy to avoid exercises that cause pain. (Tr. 276) Dr. Edwards also indicated that he would like to return Plaintiff to work without restrictions, and see her again in six weeks. (Tr. 276, 293) Plaintiff was to wear a brace when she was “up and about.” (Id.)

         Plaintiff returned to Dr. Edwards on December 13, 2012. Plaintiff reported that she was doing better, but was having problems with therapy. (Tr. 277) Plaintiff indicated that she was not having problems at work. (Id.) Dr. Edwards discontinued physical therapy and placed “[n]o restrictions” on Plaintiff, requesting that she return in five weeks “to make sure that she continues to improve.” (Id.) Dr. Edwards' Return to Work Record indicates that Plaintiff could return to work without restrictions. (Tr. 294)

         On January 17, 2013, Plaintiff returned to Dr. Edwards for a follow-up visit. Plaintiff reported intermittent symptoms. (Tr. 278) Dr. Edwards' notes indicate that he found Plaintiff had reached “MMI, ” and noted that she was “at full duty without restrictions.”[4] (Tr. 278, 295) Plaintiff was to take “an occasional anti inflammatory as well [as] migraine medicine for the knee pain. Otherwise I will see her back on an as needed basis.” (Id.)

         B. Pemiscot Memorial Hospital

         The administrative record before the Court indicates that Plaintiff received treatment at Pemiscot Memorial Hospital. (Tr. 299-352) On January 28, 2013, Dr. Jim Hazel examined Plaintiff relative to cervical spine pain. The treatment notes indicate no significant abnormality. (Tr. 299) Most of the remaining notes from Pemiscot Memorial Hospital relate to Plaintiff's rehabilitation and physical therapy associated with her left knee pain and surgeries. (See, e.g., 301-52)

         C. Caruthersville Clinic - Dr. Douglas Fitzwater, M.D.

         Apart from her orthopedic treatment with Dr. Edwards, Plaintiff also received medical treatment from Dr. Douglas Fitzwater and his clinic. (Tr. 355-65) These visits generally concerned routine medical matters such as influenza and conjunctivitis. (See, e.g., Tr. 357, 359) On January 28 and 31, 2013, Plaintiff was seen by Dr. Fitzwater due to complaints of hip pain and an arm numbness problem. (Tr. 361-65) Plaintiff was treated with a limited course of medication without any further intervention noted. (Tr. 364-65)

         D. Southeast Missouri Health Network

         Plaintiff also received treatment from providers at Southeast Missouri Health Network - Portageville, Missouri. (Tr. 365-80) Plaintiff was seen for a variety of ailments and conditions, including ankle pain, wrist issues, sinus problems, left arm numbness, congestion, adjustment disorder, and back pain. Plaintiff routinely received conservative treatment, such as a short term course of medication. (Id.)

         E. Mid-America Rehab, P.C. - Vic Zuccarello

         The administrative record includes documents from Mid-America Rehab, P.C. (Tr. 381-412) These records include notes and forms associated with a Functional Capacity Evaluation (“FCE”) completed by Occupational Therapist Vic Zuccarello, dated June 20, 2013, upon referral from Dr. Edwards. In her identification information, Plaintiff indicated that, although she had been laid off, she was looking for another job. (Tr. 412) The records also indicate that Plaintiff provided a great deal of background information in connection with Mr. Zuccarello's FCE. Plaintiff rated her pain in seven areas of life, and described her pain primarily in connection with her left knee.

         Mr. Zuccarello concluded that Plaintiff had the following demonstrated impairments:

Mild decrease in terminal L knee flexion ROM. Moderately decreased L quad strength. Mildly antalgic gait pattern consistent with guarding of LLE in climbing and lower level postures. Decreased L calf girth. She does have valid dysfunction but seems to have adapted to the changes it imposes on her current funct ional abilit y.

(Tr. 396)

         After conducting what appears to be a thorough evaluation, Mr. Zuccarello concluded that Plaintiff “display[ed] no overt functional limiting factors that would prohibit work in her prior job. She had been working full duty up to the time of lay-off and would likely still be working in that job despite some residual discomfort. She is looking for a job in the same occupation presently.” (Tr. 396) Mr. Zuccarello opined that, based on his evaluation, Plaintiff could -

function on a full-time basis in the MEDIUM work demand level as follows:
1. Material Handling: no limitations per the employer job descript ion.
2. Non-Material Handling: no limitations per the employer job ...

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