United States District Court, D. South Carolina, Aiken Division
REPORT AND RECOMMENDATION
SHIVA V. HODGES, Magistrate Judge.
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be affirmed.
I. Relevant Background
A. Procedural History
On September 22, 2009, Plaintiff filed applications for DIB and SSI in which she alleged her disability began on August 2, 2009. Tr. at 119-21, 124-30. Her applications were denied initially and upon reconsideration. Tr. at 92-93, 95-96. On July 6, 2011, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Ivar E. Avots. Tr. at 28-70 (Hr'g Tr.). The ALJ issued an unfavorable decision on October 28, 2011, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 12-23. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-3. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on February 18, 2013. [Entry #1].
B. Plaintiff's Background and Medical History
Plaintiff was 49 years old at the time of the hearing. Tr. at 38. She earned her graduate equivalency diploma. Tr. at 34. Her past relevant work ("PRW") was as a knitting machine operator, sewing machine operator, mental retardation aide, sales clerk, and shift supervisor. Tr. at 61. She alleges she has been unable to work since August 2, 2009. Tr. at 124.
2. Medical History
On June 11, 2009, Plaintiff presented to Humaira Khalid, M.D., for regular follow up of multiple medical problems. Tr. at 229. She stated that she had some back pain, but that it had been better since she had been in therapy. Id. She stated that she had foot pain when she was on her feet for 10-12 hours at work, but otherwise had been stable. Id. She reported that her blood pressure had been stable, that she was trying to be more compliant with her CPAP (continuous positive air pressure) machine, and that her migraines were stable with Topomax. Id. Dr. Khalid noted that Plaintiff should continue physical therapy and prescribed medications for her back pain, but also noted that he would order an MRI if Plaintiff had no improvement in the next month. Tr. at 230. Plaintiff was discharged from physical therapy on August 4, 2009, and it was noted that she had not returned for her visits since June 24, 2009. Tr. at 246.
On July 6, 2009, Plaintiff underwent an MRI study, which showed she had mild disc bulging and facet hypertrophy (enlargement) with no nerve root impingement in her lumbar and sacral spine. Tr. at 410-11.
On July 17, 2009, she presented to John Haasis, M.D., with complaints of increasing back pain with radiation into her right lower extremity during the prior several months. Tr. at 252. She reported having undergone conservative care including physical therapy and medication trials with no significant benefit. Id. Dr. Haasis found Plaintiff was in no apparent distress and had a mildly antalgic gait. Tr. at 254. He noted that she displayed no evidence of muscle wasting or fasciculation (muscle twitch). Id. She had decreased range of motion and tenderness to palpation of her thoracolumbar spine, a positive straight leg raising test, diminished reflexes, and difficulty standing on her toes and heels and squatting. Tr. at 255. She had full muscle strength in all of her extremities, intact sensation, and a normal examination of her knees. Id. Dr. Haasis diagnosed right lower extremity pain, obesity, degenerative joint disease of the spine, muscle spasm, degenerative disc disease of the lumbar spine, facet joint syndrome and arthropathy, myofascial pain syndrome, low back pain, and lumbosacral spondylosis. Tr. at 256. He recommended therapeutic injections under fluoroscopic guidance and prescribed Lortab. Tr. at 256.
Plaintiff returned to Dr. Haasis on August 20, 2009. Tr. at 250. He found she had point tenderness in her lower lumbar facets and increased pain with extension, but also had negative straight leg raising tests. Id. Dr. Haasis administered fluoroscopicallyguided facet injections to Plaintiff's lumbar and sacral spine and prescribed Flexeril and Lortab. Tr. at 250-51.
In September 2009, Plaintiff presented to the Greer Hospital emergency room. Tr. at 412-30. She complained of lower back pain for the prior 20 years with worsening symptoms over the preceding two days. Tr. at 423. She rated her pain as an eight on a 10-point scale. Id. She reported a history of untreated hypertension, cholecystectomy and hernia repair, depression, migraine headaches, chronic back pain, degenerative disc disease, and sleep apnea. Tr. at 424. Edward Anderson, M.D., found Plaintiff appeared uncomfortable and in moderate pain. Id. He found she had decreased spinal ranges of motion and tenderness in her lower back. Id. He diagnosed acute exacerbation of chronic low back pain and degenerative disc disease and administered a Ketorolac injection. Tr. at 424-25. He prescribed medications, including Flexeril, Lortab, Nortriptyline, and Topamax (Tr. at 425).
In December 2009, Plaintiff presented to Taylors Free Medical Clinic ("Free Clinic") reporting itching since her nerve block injection. Tr. at 431. She complained of migraine headaches, back pain, and numbness in her legs. Id. She was obese with extremity edema. Id. Diagnoses included headaches, obesity, and lower extremity edema, and the treater prescribed medications including Topamax, Fioricet, and Ultram. Id.
Plaintiff returned to the Free Clinic in January 2010 and was noted to have a longstanding back problem. Tr. at 432. It was further noted she was obese and had increased glucose and cholesterol. Id. She was prescribed Flexeril and Mobic. Id.
On February 8, 2010, Larry Korn, D.O., examined Plaintiff at the request of the state agency. Tr. at 435. Plaintiff complained of low back and knee pain. Id. Plaintiff reported that her back pain had become "really significant and worse" in the prior year and was exacerbated by doing household chores. Id. Plaintiff further stated that she could only tolerate about 10 minutes of weight bearing and could not sit long either. Id. Dr. Korn noted that Plaintiff had been fired from her job at CVS in August 2009 due to a personality conflict. Tr. at 436. Dr. Korn found that Plaintiff could do "some" limited serial threes and did not know the Vice-President's name. Id. She had a normal mood; communicated and comprehended well; spelled the word "world" backward; performed serial twos; and knew the date, day of the week, her location, and the President's name. Id.
Dr. Korn found Plaintiff was morbidly obese and had full ranges of motion in her upper extremities without crepitus, deformity, or edema. Id. She had limited joint motion in her lower extremities due to soft tissue barriers. Id. Plaintiff could squat to a point, though it was painful with some knee grinding and discomfort. Id. She did not have any obvious joint hypertrophy, but had a trace of edema in her legs. Tr. at 436-37. She had diminished reflexes in her forearms, trace reflexes at the patellae, and absent Achilles reflexes, but normal digital dexterity, and the ability to heel, toe, and tandem walk. Tr. at 437. Dr. Korn stated it was difficult to assess her spinal curvature due to her obesity, but her pelvis appeared to be level and she had negative seated straight leg raising tests. Id.
Dr. Korn diagnosed severe morbid obesity, spondylosis of the lumbosacral spine, and chondromalacia of the knees (not ruling out degenerative joint disease). Id. He stated Plaintiff's back impairments with her profound truncal obesity combined to "severely limit her ability to perform the sorts of duty she describe[d] where she [was] bending and leaning for prolonged periods of time." Tr. at 437. He stated her knees prevented her from crouching on more than an occasional basis and her obesity, knees, and low back all combined to make it very difficult for her to pick up objects from the floor level on a repetitive basis. Id. He opined that she would have difficulty picking up objects of significant weight, i.e., over 20 pounds from floor level. Id. He stated her knees and obesity limited her from climbing ladders or scaffolding and she had a "slight" challenge climbing stairs. Id.
That same day, Plaintiff underwent bilateral knee x-rays, which showed osteoarthritic changes in her knees, likely most severe in the patellofemoral compartments. Tr. at 434.
On February 22, 2010, Hugh Clarke, M.D., a state-agency physician, reviewed the evidence and stated Plaintiff could lift 20 pounds occasionally and 10 pounds frequently Tr. at 441. He stated Plaintiff could stand or walk for at least two hours and sit for about six hours each in an eight-hour workday. Id. He stated she was limited to frequent operation of foot controls bilaterally. Id. He stated she could never climb ladders, ropes, and scaffolds or kneel, but could occasionally climb ramps and stairs, balance, stoop, crouch, and crawl. Tr. at 442. He also stated she should avoid even moderate exposure to hazards (machinery, heights, etc.). Tr. at 444.
In March 2010, Plaintiff complained to the Free Clinic of upper abdominal pain and anxiety. Tr. at 452. The treating physician prescribed medications and weight loss and recommended an abdominal CT scan. Id.
Plaintiff returned to the Free Clinic in May 2010 with complaints of back problems after falling the prior month. Tr. at 451. Rebecca Smith, M.D., noted Plaintiff was obese and had mild wheezing. Id. She also found Plaintiff had lower back tenderness, but negative straight leg raising tests. Id. Dr. Smith diagnosed, among other things, low back pain with right sciatica and prescribed medications, including Naprosyn. Id.
In June 2010, Plaintiff underwent a lumbar spine x-ray at the Free Clinic, the results of which W. Clark Jernigan, M.D., stated were "normal for [her] age." Tr. at 448. In July 2010, Plaintiff complained to Dr. Smith of low back pain "so bad it w[oke] her up at night" and numbness and tingling in her right leg. Tr. at 450. She stated that, while she started taking Trazodone the prior week, she still had difficulty sleeping. Id. Dr. Smith's diagnoses included depression/insomnia, low back pain, sciatica, and hypertension. Id. She continued Plaintiff's medications and recommended back exercises. Id.
In August 2010, Plaintiff received a prescription for a Medrol Dosepak. Tr. at 449. On September 7, 2010, Plaintiff presented to the Free Clinic, where Dr. Jernigan found she had a positive straight leg raising test on the right, but a negative straight leg raising test on the left. Tr. at 482. He also found she had intact sensation; diagnosed chronic back pain; and recommended exercise, weight loss, and over-the-counter analgesics. Id.
On September 16, 2010, Plaintiff complained to the Free Clinic that she continued with chronic back pain, was depressed, and needed an antidepressant. Tr. at 483. Examination revealed Plaintiff had a venous stasis ulcer on her right leg. Id.; see also Tr. at 484. Plaintiff was prescribed medications, including Zoloft, and advised to stop smoking and lose weight. Tr. at 483.
That same day, Dale Van Slooten, M.D., a state-agency physician, reviewed the evidence and stated Plaintiff could lift and carry 20 pounds occasionally and 10 pounds frequently. Tr. at 456. He stated she could stand or walk for at least two hours and sit for about six hours each in an eight-hour workday and was limited to frequent operation of foot controls bilaterally. Id. He stated she could never climb ladders, ropes, or scaffolds or kneel, but occasionally climb ramps and stairs, balance, stoop, crouch, and crawl. Tr. at 457. He stated she should avoid even moderate exposure to hazards (machinery, heights, etc.). Tr. at 459. Dr. Van Slooten stated that Plaintiff's allegations were credible, but did not preclude the performance of all levels of work activity. Tr. at 460.
On October 14, 2010, Plaintiff returned to the Free Clinic with complaints of an ulcer on her right leg and anxiety. Tr. at 484. She stated that Zoloft "help[ed] some." Id. Dr. Smith found Plaintiff was obese with a healing ulcer on her right lower extremity. Id. Dr. Smith diagnosed venous ulcer, hypertension, and anxiety/depression. Id. She prescribed medications, including Zoloft. Id.
On October 26, 2010, Carrie Edmonds, a licensed practical counselor, stated Plaintiff could only occasionally interact with the public, and respond appropriately to work pressures and changes in a routine work setting. Tr. at 477. She stated Plaintiff had depression and anxiety as demonstrated by difficulty focusing, decreased energy and motivation, and increased sadness and crying. Tr. at 478. She stated Plaintiff was somewhat hopeless, had increased sleep, and would have difficulty managing full time employment. Id. She also stated Plaintiff was unable to consistently attend work 18 days out of 20 and would likely decompensate under the stress of simple, routine work loads of 40 hours per week. Id.
In November 2010, Dr. Jernigan stated Plaintiff could lift and carry up to 20 pounds continuously and 21 to 50 pounds frequently based on her obesity. Tr. at 479. He stated that she could sit, stand, or walk for eight hours each in an eight-hour workday. Id. He stated she did not require a cane to ambulate and could continuously reach, handle, finger, feel, push, and pull. Tr. at 480. He "[did not] know" which of Plaintiff's hands was dominant. Id. He stated Plaintiff could never climb ladders or scaffolds, but could occasionally climb stairs and ramps and continuously perform all other postural activities. Tr. at 481. He stated Plaintiff would never be absent from work as a result of her impairments or treatment. Id. When asked how often Plaintiff's pain was severe enough to interfere with attention and concentration, he stated he "ha[d] no way to know, " and stated her limitations did not last, nor were they expected to last, for 12 months. Id.
In December 2010, Plaintiff reported to the Free Clinic that she had trouble sleeping, was depressed, cried a lot, and she felt little relief with medications. Tr. at 485. She had an ulcer on her right lower leg. Id. Zoloft was discontinued and other medications, including Wellbutrin were prescribed. Id.
The following month, Plaintiff reported to the Free Clinic that her back hurt, but she "fe[lt] a little better" and her weight was down. Tr. at 487. Plaintiff's Wellbutrin was continued and weight loss was again recommended. Id. In February 2011, Plaintiff returned to the Free Clinic with complaints of depression. Tr. at 488. Dr. Smith's diagnoses included resolving right leg ulcer and agitation. ...