United States District Court, E.D. Missouri, Northeastern Division
MEMORANDUM AND ORDER
M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE.
matter is before the Court for review of an adverse ruling by
the Social Security Administration. The parties have
consented to the jurisdiction of the undersigned United
States Magistrate Judge pursuant to 28 U.S.C. § 636(c).
April 1, 2015, plaintiff Robert L. S., Jr., protectively
filed an application for supplemental security income, Title
XVI, 42 U.S.C. §§ 1381 et seq., with an
alleged onset date of February 19, 2008. (Tr. 223-26,
142). After plaintiff's application was denied on initial
consideration (Tr. 155-59), he requested a hearing from an
Administrative Law Judge (ALJ). (Tr. 164-65).
and counsel appeared for a hearing on January 26, 2017. (Tr.
64-105). Plaintiff testified concerning his disability, daily
activities, functional limitations, and past work. The ALJ
also received testimony from vocational expert Barbara Myers,
M.S. The ALJ issued a decision denying plaintiff's
applications on April 21, 2017. (Tr. 18-28). The Appeals
Council denied plaintiff's request for review on December
19, 2017. (Tr. 1-5). Accordingly, the ALJ's decision
stands as the Commissioner's final decision.
Evidence Before the ALJ
Disability and Function Reports and Hearing
who was born on August 22, 1965, was 42 years old on the
alleged onset date. He lived alone in a house in walking
distance of the homes of his parents and one of his sons.
(Tr. 86). He completed high school and had a mixture of
regular and special education classes. (Tr. 69-70). He
previously worked as a truck driver and a farm laborer. (Tr.
plaintiff applied for disability benefits in 2015, he listed
his impairments as rib fracture, bulging discs, knee
problems, shoulder problems, neck problems, and sleep
disorder. He was 5-feet, 11-inches tall and weighed 358
pounds. (Tr. 246). In a Function Report completed in May 2015
(Tr. 263-70), plaintiff stated that he had a substantial
amount of pain, which affected his abilities to walk, stand,
sit, lift, and sleep. He used a cane around the house. He
struggled to manage cooking, cleaning, bathing, and
completing household tasks and relied on his son to do more
labor-intensive chores. Plaintiff also took care of small
dogs, although his son delivered dog food for him. His
hobbies and interests included reading and watching
television. He used to be able to work, hunt, fish, and
pursue other recreational activities. As a result of his
impairments, he was unable to stand for very long and all of
his daily tasks took longer to complete. He struggled to
dress and bathe. He did not sleep well at all due to pain and
apnea. His lack of sleep affected his mood and ability to get
along with others. He had a driver's license and borrowed
his father's truck to go to medical appointments, the
lawyer's office, and grocery shopping. He had difficulty
concentrating, finishing tasks, and following instructions.
He got along “very, very poorly” with authority
and did not handle stress or changes in routine well. (Tr.
268-69). Plaintiff had difficulty with lifting, squatting,
bending, standing, reaching, walking, sitting, kneeling,
talking, stair climbing, completing tasks, concentrating,
understanding, following instructions, using his hands, and
getting along with others. He could walk “a matter of
feet” before he needed to rest for a few minutes. In a
narrative portion, plaintiff stated that he was in constant
pain and did not sleep well. All his prior work had been as a
laborer and he did not have any skills he could transfer to
another field. Plaintiff's son David also completed a
Function Report that is largely consistent with
plaintiff's report. (Tr. 274-81). David added, however,
that plaintiff was completely dependent on his son and
parents for financial support and their capacity to help was
being strained. David visited twice a week to bring supplies
and help with chores. He stated that his father was in
constant pain and had sleep apnea, was very difficult and
stubborn, and was not capable of working. Furthermore, he
added, “no one in their right mind would hire
him.” (Tr. 281).
traced his impairments to an injury in 2008. Over time, his
condition had deteriorated and he had pain from the time he
got up in the morning and it worsened throughout the day. He
testified that he had radiating pain from mid-back to his
right knee. He felt pain after standing or sitting for 15 to
20 minutes. His primary care physician had told him that he
was not a good candidate for back surgery. (Tr. 81). He spent
a large portion of the day lying on the floor to get some
relief. He also did low impact stretching and, in the summer,
swimming. He was able to walk to his father's home, a
distance of about 300 feet, to watch the news before
returning home to stretch on the floor again. Plaintiff had
also sustained several injuries to his right knee which
popped and caused pain if he took a long stride. In addition,
he had previously broken his ankle. He was able to walk about
30 to 40 minutes before he experienced knee or ankle pain.
(Tr. 72-73). He avoided climbing stairs because it caused
pain. (Tr. 98).
right rotator cuff was torn and he had a bone spur. As a
consequence, lifting weights as light as a coffee cup caused
pain. He had recently discussed surgery to address the tear
in the rotator cuff and remove part of his collar bone. (Tr.
77-78). He was undecided about whether to have the surgery.
He testified that, due to pain in his right knee, he needed
both arms to get up in the morning or rise from a chair and
he did not know how he would manage to take care of himself
after surgery if he could not use his right arm. (Tr. 78-79).
He described his left shoulder as worn out from factory work
and testified that he had bursitis. Plaintiff had been
treated with steroid injections, but the effects eventually
wore off. He also had stiffness in his neck and nerve pain in
his left arm. (Tr. 77). He had been prescribed medicines, but
they “didn't work for [him] inside [and] affect[ed
his] mental part a little bit.” He took Naproxen, which
dulled the pain somewhat. (Tr. 80, 308-09, 312).
testified that he had hypersomnia and had suffered from sleep
apnea most of his life. He began CPAP treatment in 2011 or
2012. (Tr. 84). He tossed and turned all night and catnapped
on the floor during the day. He often woke gasping for air.
Plaintiff also had depression attributed to the decline in
his physical health. He did not have an active social life,
pursue hobbies, or have friends. He interacted with his son,
who lived next door, and his parents, who lived half a block
away; he also went to town meetings, where he was generally
one of very few people in attendance. (Tr. 81-82, 86, 91,
93). He was not able to concentrate long enough to watch a
movie and had been diagnosed with attention deficit disorder
(ADD/ADHD). (Tr. 91). His physician prescribed medication for
the condition but discontinued it when it did not appear to
be helping. (Tr. 91-92). Finally, he was obese and had
tinnitus. (Tr. 82-83, 91).
response to questions from the ALJ, plaintiff testified that
he was able to prepare and clean up simple meals. His parents
had a vegetable garden that he picked from and he had what he
called “a green patch” in his yard that produced
“tender greens” and “turnip greens.”
It reseeded itself each year and he did not till it or weed
it. (Tr. 89-90). He used a rider mower to mow the lawn, a
task that took about 40 minutes, after which he was
“done for the day.” (Tr. 90). In addition, he
drove to appointments about once a month. After 20 minutes of
driving, he had a burning sensation in his tailbone and his
left leg went to sleep. (Tr. 87-88). He got a stiff neck from
holding the steering wheel and had pain in his shoulder and
nerve pain in his left arm.
expert Barbara Myers was asked to testify about the
employment opportunities for a hypothetical person of
plaintiff's age, education, and work experience who was
limited to light work, who could frequently reach overhead in
all directions bilaterally; who could never climb ladders,
ropes, or scaffolds; could occasionally climb ramps and
stairs, balance, stoop, kneel, crouch and crawl; could
occasionally operate a motor vehicle and be exposed to
vibration; and could work in a moderate noise environment.
According to Ms. Myers, such an individual would not be able
to perform plaintiff's past work, but could work as a
cashier or a collator operator. (Tr. 101-02). There would be
no work available if the individual were further restricted
to only occasional reaching in all directions bilaterally.
Similarly, there would be no work available if the individual
needed additional breaks during the work day to elevate his
legs or would be off-task 20% of the work day due to severe
pain. (Tr. 102-03).
administrative transcript includes records of plaintiff's
medical treatment as far back as 2011. During the period
under review, plaintiff had complaints of pain in his neck,
low back, and shoulders, for which he was treated with
medications, injections, and osteopathic manipulations. He
was also diagnosed with and treated for sleep apnea, diabetes
type II, gout, depression, anxiety, and attention deficit
disorder. He was morbidly obese and was provided with dietary
advice and exercise goals. In December 2013, he underwent a
laparoscopic appendectomy. Plaintiff's primary argument
is that the ALJ failed to address his complaints of shoulder
pain and improperly concluded that he was capable of reaching
overhead and in all directions frequently. Accordingly, the
Court here discusses medical records bearing on this issue.
April 15, 2013, plaintiff sought treatment at the Northeast
Missouri Health Council, Inc., from primary care physician
Melanie S. Grgurich, D.O., for pain in his right
shoulder. He reported that he felt it twist and pop
while he was planting a garden. (Tr. 740-42). At that time,
he refused imaging studies, pain medications, or referrals. A
month later, he complained of bilateral shoulder pain that
was aggravated by lifting and pushing. (Tr. 736-39). He
experienced numbness, popping, locking, weakness, and
tingling in his arms. He also complained of decreased
mobility and insomnia. On examination, Dr. Grgurich noted
that plaintiff had tenderness of the lumbar spine and
shoulders. She gave plaintiff an injection of Toradol and
encouraged him to go to a pain clinic. X-rays of the right
shoulder showed normal glenohumeral articulation, mild
downsloping acromion, and minimal osteoarthritis. With
respect to the rotator cuff, the x-rays showed a small
ossicle or the distal clavicle projecting over the rotator
cuff, predisposing plaintiff to impression on the cuff. There
was also suspected calcific tendinosis of the rotator cuff.
(Tr. 332-33). On June 4, 2013, he continued to have reduced
range of motion and tenderness in his shoulders. (Tr.
733-35). Dr. Grgurich administered a steroid injection to his
left shoulder. Two weeks later, he reported that the
injection provided pain relief for two days.
saw pain specialist Theresa T. Rickelman, D.O., on June 20,
2013. (Tr. 334-36). Plaintiff reported that he had pain in
his neck, left arm and shoulder, low back, and legs. He also
had numbness in his left arm and left leg, a sharp ache in
his hands, and shooting pain in his left leg. On examination,
Dr. Rickelman noted that plaintiff appeared to be in distress
and was unable to sit in one position for any length of time.
He needed assistance to heel-toe walk and squat. Forward and
backward bending increased his low back pain and any movement
of the left arm caused increased pain, especially in the
shoulder. Dr. Rickelman noted that plaintiff's MRIs were
very difficult to interpret due to his size but stated that
it appeared he had degenerative disease in the low back and
facet arthritis and degenerative disease in the cervical
spine. Plaintiff complained that steroids made him jittery,
so she prescribed Neurontin and Mobic. She directed him to
exercise in water. Although he would have benefited from