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Knichel v. Berryhill

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

June 13, 2017

MICHELLE KNICHEL, Plaintiff,
v.
NANCY A. BERRYHILL[1], Acting Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          CAROL E. JACKSON, UNITED STATES DISTRICT JUDGE

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

         I. Procedural History

         On November 25, 2013, plaintiff Michelle Knichel protectively filed an application for supplemental security income with an alleged onset date of July 10, 2010. (Tr. 272-75).[2] After plaintiff's application was denied on initial consideration on December 31, 2013, (Tr. 149-52; 128-36), she requested a hearing from an Administrative Law Judge (ALJ). (Tr. 153).

         Plaintiff and counsel appeared for a hearing on November 20, 2014 (Tr. 86- 120, 169). The ALJ issued a decision denying plaintiff's application on January 9, 2015. (Tr. 63-70). The Appeals Council denied plaintiff's request for review on March 21, 2016. (Tr. 1-7). Accordingly, the ALJ's decision stands as the Commissioner's final decision.

         II. Evidence Before the ALJ

         A. Disability Application Documents

         In a November 25, 2013, Disability Report, [3] (Tr. 276-85), plaintiff listed her medical conditions as (1) anxiety with panic attacks, (2) arthritis “throughout whole body, ” (3) left ankle with pins, screws, and plates, (4) a left knee that she could not walk on, (5) “nerve damage throughout body from car wreck, ” (6) “right shoulder messed up, ” (7) “right rib keeps popping out of place, ” and (8) depression. (Tr. 277). Plaintiff reported that in July 2010, these conditions became so severe that they prevented her from returning to work following her lay-off. (Tr. 277-78). Plaintiff reported that she had completed the eleventh grade and did not obtain a GED. She did not attend special education classes, and did not complete any type of specialized training, trade, or vocational school. Id. She listed her prior work experiences as a caregiver (2000-2001), housekeeper (2009-2010), and waitress (1999-2000). (Tr. 279). Plaintiff listed her medications as Buspirone for anxiety, [4]Diclofenac for advanced arthritis, [5] an indecipherable pain medication, and prenatal vitamins. (Tr. 280).

         A November 25, 2013, Disability Field Report (Tr. 272-75) listed plaintiff's prior Social Security income application decision dates as August 12, 1999, March 31, 2006, September 9, 2009, and March 31, 2011. (Tr. 273). Social Security Administration official K. Braswell indicated that she did not observe plaintiff experiencing difficulties in hearing, reading, breathing, understanding, coherency, concentrating, walking, or answering. (Tr. 274). She further described plaintiff as “friendly and easy to interview, ” “pleasant throughout the interview, ” and as having “clear speech.” Id.

         In an updated Disability Report, dated April 5, 2014, plaintiff reported that some changes in her condition had developed in January 2014. (Tr. 317-22). Plaintiff did not specifically identify the changes, but noted her recent doctors' visits and the reasons for them. Plaintiff saw Craig Ruble, M.D., on January 20, 2014 (among other unlisted dates) for a consultation, x-rays, surgery, and post-surgery check-up. (Tr. 318). She stated that she also had an appointment at Resolutions Behavioral Health on February 24, 2014, to treat her anxiety, depression, and bipolar disorder; she also sought to obtain prescription refills. (Tr. 318). She also had a blood test and x-rays on her left knee and ankle in 2013. (Tr. 319). Plaintiff listed her medications as Latuda for anxiety and depression, [6] Meloxicam for arthritis, [7] Norco for pain, [8] Ranitidine for acid reflux, [9] Risperidone for panic attacks and anxiety, [10] and Trazodone for insomnia.[11] Id. Plaintiff reported that she had anxiety and bipolar disorder and that her short- and long-term memory were “bad.” (Tr. 320). She noted that her hands and arms were “all messed up” and that her left leg and arthritis were in “bad shape.” Id. Finally, plaintiff complained of migraine headaches. Id. Despite these problems, she stated that there had been no alterations in her daily activities since her last report. Id.

         In a Function Report dated December 10, 2013, (Tr. 298-308), plaintiff stated that she lived in a house with her mother, son, and daughter. In response to a daily activities inquiry, plaintiff stated that she arose at around 7:00 a.m. and took her sixteen-year old son to school. Plaintiff noted that her son did not require much care, but she did his laundry and took him to school and to his sports activities. Plaintiff reported that taking care of her three-month old daughter took up most of her time. According to plaintiff, her daughter had been sick since birth and plaintiff had to “hold her a lot.” (Tr. 298). Plaintiff also watched television or took a nap with her daughter. In the evening, plaintiff helped her mother with laundry and dishes. She explained that her mother took care of most of the household chores. Plaintiff went to bed around 9:30 or 10:00 p.m.

         Plaintiff stated that since her automobile accident in 1999, she had experienced serious difficulties with her left leg and foot. Id. She added that she had problems with her left arm and right shoulder, and that she does not know how many surgeries she will require. Plaintiff also reported that she had broken her ribs, and that they would not “stay when Dr. Greenlee work[ed] on her.” (Tr. 299). Additionally, plaintiff claimed that had been in “constant pain” since the onset of her disabling conditions. Id.

         Plaintiff stated that she could generally tend to her personal care. She expressed no difficulties in dressing, bathing, shaving, feeding herself, or using the toilet. Id. But, she explained that sometimes she needed assistance with her hair because her wrists would be “messed up.” Id. She did not require any reminders to tend to her personal needs and grooming. (Tr. 300). But, she stated that she needed reminders from her mother to take her medications. Id.

         Plaintiff could also prepare her own meals every day. Id. She cooked “complete meals” about three or four times each week, but otherwise made sandwiches or other “easy stuff.” Id. Meal preparation took anywhere from ten to twenty minutes or, occasionally, as much as two hours. Id. Plaintiff noted that her left leg and foot were sometimes too swollen for prolonged standing. Id. Also, she stated that her left knee and ankle sometimes buckled and she would fall. Id. Plaintiff stated that she could do some household chores. She reported that she could accomplish a little at a time until her arms or left leg gave out. Id. Outdoor chores were not possible because plaintiff's body was “very arthritic”; she also noted her scoliosis and bulging discs. (Tr. 301).

         Plaintiff reported that went outside every day. Id. She could drive a car, ride in a car, or use public transportation. Id. And she could do so alone. Id. Plaintiff went to the store about two times each week, for about thirty to forty-five minutes, to shop for food and necessities. Id. In addition, plaintiff went to doctors' appointments. (Tr. 302). Plaintiff did not need reminders to go places. Id. She stated that she would have severe panic attacks and anxiety around crowds. (Tr. 301, 304).

         Plaintiff could also manage money in most respects. She could pay bills, count change, and use a checkbook or money orders. (Tr. 301). Plaintiff also had several hobbies and interests, including reading, watching television, resting, and spending time with her children. (Tr. 302). She stated that she used to “do everything with [her] son, ” until 2010. Id. Since then, she said, “everything has progressively gotten worse.” Id. She specifically mentioned her frequent falls. Id. Plaintiff also engaged in social activities, and spent time with others. Id. She talked to her family on the phone, or spent time with them at her house. Id. Plaintiff seldom used the computer, and if she did, it would only be for a few minutes. Id. Plaintiff stated that she sometimes had problems getting along with others, as she could not handle “all the people”; she would get nervous and her heart would race. (Tr. 303).

         Plaintiff stated that her conditions inhibited her abilities to (1) lift more than ten pounds, (2) squat, (3) bend, (4) stand for more than ten to fifteen minutes, (5) reach, (6) walk for more than ten to fifteen minutes, (7) sit, [12] (8) kneel, and (9) climb stairs. Id. When walking, plaintiff required ten to fifteen minutes of rest, every ten to fifteen minutes. Id. She could only use her hands for a short time. Id. Plaintiff also expressed difficulties with her memory, concentration, completion of tasks, and handling of stress. (Tr. 303-04).

         B. Testimony at Hearing

         Plaintiff testified that the medical conditions preventing her from maintaining employment included left ankle pain, nerve compression in her left leg, locking of her left knee, right shoulder pain and arthritis, double vision, migraine headaches, and anxiety. (Tr. 96-97).

         Plaintiff testified that she received treatment for her ankle from Dr. Craig Ruble, an orthopedic surgeon. (Tr. 97). Dr. Ruble removed hardware from plaintiff's ankle earlier in 2014, but she testified that her ankle “still hurts” and “still locks.” Id. According to plaintiff, standing increased her pain though she still experienced left leg pain while sitting down. Id. She testified that she walked with a limp. Id. She could only stand for twenty minutes before her knee or ankle would lock and cause her to fall. (Tr. 98). And plaintiff could walk for about fifteen minutes before she would need to stop and rest to preventing locking. (Tr. 99).

         Plaintiff also testified about her right shoulder pain. She stated that sitting for long periods caused intense shoulder pain. Id. Specifically, she could only sit for about fifteen to twenty minutes before she needed to stand. Id. She also had pain while extending or reaching her arm. (Tr. 100). Dr. Ruble performed a surgery on plaintiff's right shoulder in June 2014. (Tr. 111). She stated that during her follow-up visit, she reported continuing pain, and was told that the recovery process could take up to a year and another surgery could possibly be required. Id.

         Plaintiff testified about her left leg injury. (Tr. 101). She specifically told the ALJ that she received a nerve decompression surgery on that leg. Id. She continued to experience tingling and numbness after the surgery. Id.

         Plaintiff also described her left knee injury and condition. (Tr. 102). She stated that she shattered her knee in several places in a car accident. Id. After the accident, doctors implanted metal hardware in her knee. Plaintiff later required surgery on her knee to “remove a lot of the arthritis in it.” Id. Plaintiff testified that because her knee locked, it would often give out and she would collapse. Id. This would occur if she walks for about twenty to thirty minutes without resting or sitting down. Id.

         Plaintiff testified about her rheumatoid arthritis condition. Plaintiff testified that she could not use a computer or type due to her rheumatoid arthritis. (Tr. 100). She specifically stated that the condition caused hand cramping, and she could not grip. Id. Plaintiff had not seen a rheumatologist to diagnose the condition at the time of the hearing. (Tr. 112).[13] Furthermore, the medication she required for treatment of her hepatitis C inhibited her ability to take medication for her rheumatoid arthritis. Id.

         D. Medical Records

         Plaintiff reported to Midwest Health Group, LLC, for an appointment with Gina Heberlie, N.P., on December 13, 2012. (Tr. 469). The notes indicate that plaintiff presented with “ganglion of tendon sheath, ” which began one year prior to this visit. Id. Notes further state that the pain was “of moderate intensity, ” and that plaintiff experienced symptoms several times daily. Id. Plaintiff stated that nothing relieved her symptoms. Id. Notes on plaintiff's musculoskeletal system state that plaintiff was “positive for myalgias, ” secondary to the metal in plaintiff's left knee. Id. Plaintiff also reported chronic pain since 2002, which affected her lower back. Id. A musculoskeletal exam showed a “normal gait, ” “decreased range of motion” in plaintiff's left knee flexion and extension, “pain with range of motion” in left shoulder adduction, and a two-centimeter “ganglion type nodule of the dorsal left wrist. (Tr. 471). Nurse Heberlie prescribed Flexeril to treat plaintiff's myalgia. (Tr. 472). She also referred plaintiff to a general surgeon regarding her ganglion of tendon sheath. Id. A visit on January 14, 2013, reported nearly identical notes on plaintiff's musculoskeletal system. (Tr. 464-66).

         On April 21, 2013, Craig R. Ruble, M.D., noted plaintiff's shoulder joint pain and impingement syndrome of the shoulder region. (Tr. 547).

         Plaintiff presented to Washington County Memorial Hospital on October 2, 2013, for treatment of hepatitis C, among other issues. (Tr. 524-26). Angie DeClue, F.N.P., observed no edema or musculoskeletal abnormalities. (Tr. 525).

         On October 18, 2013, plaintiff received an evaluation of her left knee and ankle from Daniel J. Martin, Jr., M.D. (Tr. 514). In his summary of plaintiff's history, he wrote that plaintiff had undergone open reduction internal fixation of “her left ankle several years ago with a severe trauma as well as an injury to her left knee, ” and that she “had the hardware removed from her left knee.” Id. He then noted that “[r]adiographs of the left knee show a varus alignment, ” but she had “good maintenance of the joint space.” Id. Dr. Martin explained that plaintiff's “ankle has advanced degenerative arthritis with post-traumatic changes.” Id. His examination of plaintiff's left knee also showed a “varus alignment, ” intact neurocirculatory exam, stable collateral ligaments, and negative results on the Anterior Drawer and Lachman tests. Id. He observed crepitus with range of motion of the left ankle and well-healed surgical scars. Id. He ordered an MRI of plaintiff's left knee. Id.

         Plaintiff visited Washington County Memorial Hospital complaining of shoulder pain, among other issues on November 15, 2013. (Tr. 520-23). Plaintiff told Shelley Lee, D.O., that she had experienced shoulder pain for some time. (Tr. 520). Plaintiff told Dr. Lee that heat and over-the-counter medications did not ease her pain. Id. No musculoskeletal abnormalities were noted after her physical exam. (Tr. 522).

         Plaintiff presented to Washington County Memorial Hospital on November 25, 2013, complaining of worsening anxiety. (Tr. 516). She claimed that her right shoulder pain exacerbated her anxiety. Id. A review of plaintiff's musculoskeletal system showed right shoulder tenderness and mild pain with motion. (Tr. 517-18). The prescribed plan included an orthopedic evaluation. Id.

         On November 26, 2013, plaintiff received a right shoulder x-ray at Washington County Memorial Hospital, pursuant to plaintiff's complaints of pain. (Tr. 528). Gaspar Fernandez, M.D., the reading physician, found that plaintiff had (1) an intact clavicle, (2) a normally aligned acromioclavicular joint, (3) no evidence of fracture, dislocation, focal osteolytic or osteoblastic lesions of the proximal humerus, (4) no hypertrophic or erosive changes, and (5) intact ribs. He concluded that no acute osseous abnormalities were identified and that “if internal derangement is suspected, ” an MRI could be conducted. Id.

         On December 17, 2013, plaintiff visited Jefferson County Orthopaedic Surgery and Sports Medicine for left medial and lateral knee pain, as well as medial and lateral ankle pain. (Tr. 631). Plaintiff stated that she began experiencing “problems after she had fractured her knee and ankle after being involved in a motor vehicle crash back in 1999.” Id. Plaintiff also reported surgeries on both her left knee and left ankle. Id. Plaintiff indicated several ongoing symptoms in her left knee, including a constant ache of the anteromedial and lateral knee, occasional swelling, popping, catching, locking, a sensation of instability, and some numbness over the lateral fibular region. Id. She added that walking and other activity aggravated her pain, while sitting alleviated her pain. Id. Dr. Craig Ruble conducted a detailed physical exam, which showed well-healed incisions in plaintiff's knee, with no obvious swelling, erythema, or heat. (Tr. 632). Further, Dr. Ruble noted that she “demonstrated 0 degrees of extension and 125 degrees of flexion with obvious crepitus palpated.” Id. Her ligaments were stable and she had a positive Tinel sign at the left common peroneal nerve at the fibular neck. Id. She showed no calf tenderness.

         Dr. Ruble also examined plaintiff's ankle. He noted well-healed scars and mild soft tissue swelling, with tenderness to palpation over the medial ankle. Id. “She had slightly decreased flexion and decreased rotation of the left ankle.” Id. He described plaintiff's right lower extremity as “within normal limits, ” “unremarkable, ” and “neurovascularly intact.” Id. A diagnostic study of plaintiff's ankle showed “plates and screws laterally with a sutured anchor in the medial ankle”. (Tr. 632, 634). Imaging also revealed bone-on-bone degenerative joint disease. Id. Images of plaintiff's left knee showed “previous fractured lateral tibial plateau” with removed hardware. Id.

         Dr. Ruble concluded that plaintiff had ankle pain arising from post-traumatic degenerative joint disease, painful orthopedic hardware in the left ankle, and knee pain from “questionable medial and lateral meniscus tearing and probable compressed common peroneal nerve [in the] left knee.” Id. Dr. Ruble recommended several treatments including (1) icing and elevating the knee and ankle frequently, (2) taking a Mobic[14] prescription with intermittent doses of Tylenol, (3) stopping smoking, (4) beginning a home ...


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