United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
PATRICIA L. COHEN, UNITED STATES MAGISTRATE JUDGE.
Barnard (Plaintiff) seeks review of the decision of Defendant
Nancy Berryhill, Deputy Commissioner of Operations, Social
Security Administration (SSA), denying his application for a
period of disability and Disability Insurance Benefits under
the Social Security Act. Because the Court finds that
substantial evidence supports the decision to deny benefits,
the Court affirms the denial of Plaintiff's application.
Background and Procedural History
February 2013, Plaintiff filed an application for a period of
disability and Disability Insurance Benefits. (Tr. 129-130).
The SSA denied Plaintiff's claims, and he filed a timely
request for a hearing before an administrative law judge
(ALJ). (Tr. 70-76). The SSA granted Plaintiff's request
for review and conducted a hearing on February 2, 2015. (Tr.
33-42). In a decision dated April 13, 2015, the ALJ found
that Plaintiff had not been under a disability, as defined in
the Social Security Act, through September 30, 2014, the date
last insured. (Tr. 22). The SSA Appeals Council denied
Plaintiff's subsequent request for review of the
ALJ's decision. (Tr. 1-5). Plaintiff has exhausted all
administrative remedies, and the ALJ's decision stands as
Defendant's final decision. Sims v. Apfel, 530
U.S. 103, 106-07 (2000).
Evidence Before the ALJ
then forty years of age, appeared with counsel at the
administrative hearing on February 2, 2015. (Tr. 35).
Plaintiff stated that he had been unable to work since
November 2011 due to issues with “mobility and
pain.” (Tr. 32, 37). Plaintiff stated that he could not
stand for more than thirty minutes without pain and he only
felt relief when lying down. (Tr. 37-39). Plaintiff had to
lie down five to six times per day, and even after lying down
to sleep, he woke up in pain. (Id.). Plaintiff
stated that the most he could lift was five to ten pounds.
(Tr. 39). Plaintiff explained that Dr. Alan Morris and
Physician's Assistant Ryan Rogers assigned him
significant workplace limitations. (Tr. 35).
regard to activities of daily living, Plaintiff stated that
he was unable to perform yard work or vacuum. (Tr. 40).
Plaintiff testified that he experienced both good and bad
days, but generally had two to three bad days per week. (Tr.
40). Plaintiff explained that even if he had a sit-down job,
there would be days he could not work or would have to go
home early. (Id.).
briefly questioned Plaintiff about a Cooperative Disability
Investigation (CDI).(Id.). Specifically, the ALJ
examined Plaintiff in regard to the CDI investigator's
observations that Plaintiff “was using the cane one
hand to the other.” (Id.). Plaintiff explained
that he “shifted” the cane between hands because
he was right-handed so, when he had to “carry
something, ” he moved the cane from his right hand to
his left hand but “surgery on my left shoulder makes it
a little uncomfortable. . . when I have to put weight on my
cane . . . . It hurts so I switch sides . . . .”
Relevant Medical Records
February 15, 2012, Plaintiff saw Dr. Jennifer Szalkowski, his
primary care physician, and complained of the following: (1)
intermittent middle- and lower-back pain radiating to both
thighs; (2) numbing and tingling in his legs; (3) insomnia
for several months; and (4) a bulge in his abdomen upon
straining. (Tr. 252-253). Dr. Szalkowski's objective
examination revealed “bilateral thoracic tenderness,
paravertebral muscle spasm, bilateral thoracic tenderness,
and bilateral lumbosacral tenderness.” (Tr. 255). Dr.
Szalkowski ordered an x-ray of Plaintiff's lumbosacral
spine and prescribed him Mobic, Robaxin, and Ambien. (Tr.
255-258). The x-ray of Plaintiff's lumbar spine revealed
no radiographic abnormality. (Tr. 352).
21, 2012, Plaintiff visited Dr. Dale Klein at Pain Management
Rehabilitation, complaining of worsening back and leg pain
that had caused him to discontinue employment. (Tr. 238).
Plaintiff also said that his pain was exacerbated when he
stood for extended periods and was relieved through rest.
(Id.). Plaintiff reported that over-the-counter
analgesics provided little relief and hydrocodone provided
mild relief. (Id.). Dr. Klein diagnosed Plaintiff
with lumbar radicular syndrome and myofascial pain syndrome,
and he noted possible facet arthropathy. (Tr. 241). On May
29, 2012, Plaintiff returned to Pain Management
Rehabilitation to review his MRI, which showed mild disc
bulging and facet osteoarthritis. (Tr. 237, 242). Dr. Klein
recommended “conservative therapies” and noted
that Plaintiff “desires to have a prescription for a
controlled substance. At this time, I do not feel comfortable
providing a prescription for a controlled substance
analgesic.” (Tr. 242-43). When Plaintiff saw Dr.
Szalkowski on May 31, 2012, he reported “issues with
Dr. Klein” and said he was “now looking for a new
pain provider.” (Tr. 274).
28, 2012, Plaintiff saw Dr. Szalkowski for back pain, renal
impairment, and ear pain, and Dr. Szalkowski increased his
Tramadol. (Tr. 280). On August 8, 2012, Plaintiff complained
of worsening back pain, and Dr. Szalkowski changed
Plaintiff's medication from Robaxin to Skelaxin. (Tr.
287-89). In September 2012, Plaintiff saw Dr. Szalkowski two
more times for back pain, abnormal kidney function, elbow
pain, and depression. (Tr. 299, 403, 407). On September 25,
2012, he reported that he was “overall pain free”
and displayed normal mobility of his back. (Tr. 403).
October 26, 2012, Plaintiff presented to the emergency room
at Barnes-Jewish St. Peters Hospital due to
“traumatic” back pain. (Tr. 356). Plaintiff
stated that he injured his back while moving his grandfather,
who was quadriplegic. (Tr. 357). The doctor diagnosed him
with sciatica and prescribed Vicodin. (Tr. 357).
February 18, 2013, Plaintiff saw Dr. Margaret Grisell, an
orthopedic surgeon, for back pain. (Tr.433). Dr. Grisell
noted that her examination was “limited by his being in
pain that is out of proportion to the exam[.]” (Tr.
437). Plaintiff returned to Dr. Grisell on April 15, 2013,
and she noted that Plaintiff “continues to have pain
that is out of proportion to the examination.” (Tr.
442). Dr. Grisell wrote: “I again reviewed his imaging
with him, and we talked about his diffuse degenerative
changes in his low back and the fact that these are really
very mild.” (Tr. 443). She concluded she had “no
surgical intervention to offer him” and referred him to
pain management. (Id.).
saw Dr. Richard Gahn, a pain medicine specialist on April 30,
2013, complaining of “persistent low back pain
radiating into the left buttock and posterior aspect of the
left leg intermittently as far down as the calf and
ankle.” (Tr. 453) Plaintiff's MRI revealed
“moderate disc degeneration at ¶ 3-4, L4-5, and
L5-S1.” (Tr. 455). On May 7, 2013, Dr. Gahn
administered a lumbar steroid injection. (Tr. 456).
August 20, 2013, Plaintiff underwent an MRI of the cervical
spine without contrast, which showed “small right
paracentral disc protrusion at ¶ 3-C4 with mild right
uncovertebral joint osteoarthritis with mild right neural
foraminal narrowing.” (Tr. 488). An MRI of
Plaintiff's lumbar spine without contrast showed mild
degenerative disc disease at ¶ 4-S1. (Id.).
September 10, 2013, Plaintiff presented to the emergency room
at St. Joseph Hospital West with neck, back, and leg pain
after a fall. (Tr. 578). Plaintiff exhibited normal range of
motion and tenderness in his midline upper lumbar area. ...