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Spoonemore v. Berryhill

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

October 6, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1]Defendant.



         Plaintiff Ellen Spoonemore brings this action seeking judicial review of the Social Security Commissioner's decision to deny her application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 405(g), et seq. Judicial review of the Commissioner's final decision under Title II is available under Section 205(g) of the Act. 42 U.S.C. § 405(g). Because the Commissioner's decision is supported by substantial evidence on the record as a whole, I will affirm the decision.

         Procedural Background

         Spoonemore filed her application for disability insurance benefits in August 2013, claiming she became disabled on July 1, 2006, because of torn ankle tendons, locked hip, severe pain in both knees, lower back pain, and diverticulitis. The Social Security Administration denied her application for benefits in September 2013. On August 21, 2014, a hearing was held before an administrative law judge (ALJ) at which Spoonemore and a vocational expert testified. On November 20, 2014, the ALJ denied Spoonemore's claim for benefits, finding that her impairments were not severe on or before December 31, 2011, the date she was last insured. On February 2, 2016, the Appeals Council denied Spoonemore's request for review of the ALJ's decision. The ALJ's decision is thus the final decision of the Commissioner. 42 U.S.C. § 405(g).

         In this action for judicial review, Spoonemore argues that the ALJ erred in finding at Step 2 of the sequential analysis that her impairments were not severe. Spoonemore specifically argues that the ALJ's evaluation of her credibility and the medical and opinion evidence of record improperly imposed a higher burden on her at this step of the analysis. Spoonemore also argues that the ALJ failed to fully develop the record by not obtaining the services of a medical expert to infer a reasonable onset date of the degree of limitations documented in the record. For the reasons that follow, the ALJ's decision is supported by substantial evidence.

         Evidence Before the ALJ

         Spoonemore's Testimony

         At the hearing on August 21, 2014, Spoonemore testified in response to questions posed by the ALJ and counsel. At the time of the hearing, Spoonemore was fifty-eight years old. She lived in an apartment with her boyfriend who was then drawing disability from the Veteran's Administration. She completed the eleventh grade in high school and can read, write, and do basic math. (Tr. 36-38.)

         Spoonemore testified that she does not currently work, and has not worked since 2006. Her most recent job was at Lucky's convenience store, where she worked as a store clerk. Her previous jobs before Lucky's were also in retail at convenience stores or gas stations. Spoonemore testified that she stopped working at Lucky's because of severe swelling and pain in her ankles as well as some knee pain and stiffness. Spoonemore testified that she stood all day while working ten-hour shifts at Lucky's and regularly lifted about twenty to thirty pounds. Her employer provided her with a stool so that she could sit when there were no customers in line, but Spoonemore testified that the amount of time she could sit totaled one or two hours out of her ten-hour work day. She never used an assistive device for walking or standing. (Tr. 36, 40-42, 48-49.)

         Spoonemore testified that she sought treatment for ankle pain in 2005 from Ozarks Medical Center and that an MRI showed joint issues and possible arthritis. She understood at the time that she had torn tendons or ligaments. She testified that the doctor told her surgery was an option but otherwise did not give her a treatment plan. She did not have any other appointments with this doctor. Spoonemore testified that she did not have health insurance at the time, so she went to Shannon County Family Clinic, which was a “sliding scale” clinic that allowed her to pay cash. She testified that the clinic was unable to prescribe any type of treatment for her, so she treated her ankle pain with ice, elevation, and ibuprofen. (Tr. 43-44, 50-53.)

         Spoonemore testified that a few months after she left Lucky's, she tried to find a job where she did not need to stand but was unsuccessful in her search. She testified that she did not apply for disability at the time because her boyfriend, who was then working, said he would take care of her. She testified to substantial weight gain since she left work, reporting her weight in 2006 to be 170 to 180 pounds and her current weight to be 270 pounds. (Tr. 37, 42, 49.)

         When asked specifically about her physical abilities in 2011, Spoonemore testified that she experienced some difficulty squatting and kneeling and had some pain going up and down stairs. She had no difficulty sitting or with lifting. She could stand for forty-five minutes to an hour at any one time and had no difficulty walking on smooth surfaces. She never used an assistive device for walking. Spoonemore testified that she performed household chores such as sweeping, mopping, cleaning, laundry, and cooking but that she spread these chores out over several days. She went fishing several times during the summer, but always took a chair so she could sit. (Tr. 36, 53-57.)

         Medical Evidence

         On August 10, 2005, Spoonemore underwent an MRI of the right ankle at Ozarks Medical Center for ankle pain and possible peroneal tendon pathology. Results showed joint effusion, bone marrow edema of the talus and calcaneus, and subcutaneous soft tissue edema, but there was no evidence of ligamentous or tendon injury. The MRI also suggested subtalar arthritis. No plan for treatment or for follow up is noted. (Tr. 218.)

         Between October 2005 and December 31, 2011, Spoonemore visited the Shannon County Family Clinic (the Clinic) on fourteen separate occasions. These encounters were generally for follow up on her diagnosed hypertension, thyroid, and epigastric/gastrointestinal conditions. Numerous additional notations were made during this period documenting associated medication refills and test results. Spoonemore also sought treatment for acute health issues during this time, such as for cough and tooth pain, and she also occasionally complained of mid-back pain. At no time during this period did Spoonemore complain to her healthcare providers that she experienced any pain or other issues involving her hips, knees, or ankles, or that she experienced any limitations because of any health issues. (Tr. 236-257.)

         On January 30, 2007, Spoonemore visited the Clinic with complaints of having symptoms associated with a head cold. Although she made no complaints regarding ankle pain, general musculoskeletal examination showed ankle tenderness. No treatment was given for this tenderness, nor were any treatment recommendations made. (Tr. 253-55.) On August 2, 2007, musculoskeletal examination was normal with no soft tissue swelling ...

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