United States District Court, D. South Carolina, Aiken Division
SHIVA V. HODGES, Magistrate Judge.
This appeal from a denial of social security benefits is before the court for a final order pursuant to 28 U.S.C. § 636(c), Local Civil Rule 73.01(B) (D.S.C.), and the order of the Honorable J. Michelle Childs dated July 16, 2013, referring this matter for disposition. [Entry #6]. The parties consented to the undersigned United States Magistrate Judge's disposition of this case, with any appeal directly to the Fourth Circuit Court of Appeals.
Plaintiff files this appeal pursuant to 42 U.S.C. § 405(g) of the Social Security Act ("the Act") to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying the 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 court affirms the Commissioner's decision.
I. Relevant Background
A. Procedural History
On January 27, 2010, Plaintiff filed applications for DIB and SSI in which she alleged her disability began on December 31, 2009. Tr. at 98, 100. Her applications were denied initially and upon reconsideration. Tr. at 102-06, 112-13, 114-15. On February 3, 2012, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Frances W. Williams. Tr. at 28-78 (Hr'g Tr.). The ALJ issued an unfavorable decision on March 9, 2012, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 7-25. 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 June 13, 2013. [Entry #1].
B. Plaintiff's Background and Medical History
Plaintiff was 48 years old at the time of the hearing. Tr. at 32. She completed the tenth grade. Tr. at 33. Her past relevant work ("PRW") was as a cashier, a custodian, a custodial supervisor, a sandwich maker, a garment folder, and a daycare worker. Tr. at 72. She alleges she has been unable to work since December 31, 2009. Tr. at 36.
2. Medical History
Plaintiff underwent multiple surgeries to her bilateral knees prior to the alleged onset date of disability. On January 5, 2006, Plaintiff underwent arthroscopic partial medial meniscectomy of the right knee, arthroscopic excision of the synovial plica, and arthroscopic abrasion chrondroplasty of the medial femoral condyle. Tr. at 275-76. Plaintiff underwent arthroscopic osteochondral autograft transplantation and partial medial meniscectomy of the left knee on July 11, 2006. Tr. at 278-79. On March 18, 2008, Plaintiff underwent arthroscopic lysis of adhesions of the left knee medial capsule and abrasion chondroplasty of the trochlear groove. Tr. at 308.
Also prior to the alleged onset date, Plaintiff complained of right shoulder pain. On November 20, 2008, Plaintiff followed up with Dr. Thomas Ewart for right shoulder pain and MRI results. Tr. at 301. Dr. Ewart reviewed the MRI and concluded that Plaintiff had a supraspinatus tear and some labral degeneration. Id. After conservative treatment for the right shoulder failed, Plaintiff was scheduled for right shoulder subacromial decompression, Mumford resection, and rotator cuff repair on October 8, 2009. Tr. at 395. However, on October 13, 2009, Plaintiff informed Dr. Ewart that she cancelled her right shoulder surgery due to having the flu and that she could not reschedule the surgery because she had to work. Tr. at 394. Dr. Ewart observed restricted motion in Plaintiff's right shoulder with abduction reduced to 110 degrees and internal and external rotation reduced to 60 degrees. Id.
Plaintiff also complained of neck pain before her alleged onset date. On October 28, 2009, Plaintiff presented to Dr. Ewart with complaint of neck pain. Tr. at 393. Dr. Ewart observed no acute impairment and advised Plaintiff of possible treatment. Id. Xray of the cervical spine on November 5, 2009, indicated mild spondylolytic changes at C4-5 and C5-6. Tr. at 442.
Plaintiff complained of increased left knee pain in the fall of 2009. MRI of the left knee on November 10, 2009, revealed moderate degenerative arthrosis changes of the medial compartment with a degenerative horizontal tear of the posterior and medial horns of the medial meniscus and a moderate-sized joint effusion with multiple thin internal septations. Tr. at 289.
On her alleged onset date of December 31, 2009, Plaintiff underwent arthroscopic partial medial meniscectomy of the left knee, which was performed by Dr. Ewart. Tr. at 346-47.
On March 11, 2010, Plaintiff presented to her primary care physician Beena Varugheses, M.D., for follow up regarding hypertension and diabetes mellitus. Tr. at 384-85. Plaintiff complained of moderate left knee pain and blurred vision. Tr. at 384. Plaintiff's blood sugar and hypertension were noted to be well-controlled. Tr. at 385.
Plaintiff followed up with Dr. Ewart on March 16, 2010. Tr. at 388. Dr. Ewart indicated that he could do nothing else for Plaintiff because injections had not helped and Plaintiff was too young for joint replacement. Id. He recommended that Plaintiff "not take any job that requires standing and walking due to severe arthritis in the knee." Id. He referred Plaintiff to Deanna Constable, M.D. Id.
On March 18, 2010, Plaintiff followed up with Dr. Varugheses. Tr. at 484-86. She complained of intermittent episode of pain in the right parietal scalp area and left knee pain. Tr. at 484. Plaintiff reported that she lost her job because her employer could not comply with her light duty restriction. Id. Plaintiff indicated that she had applied for social security. Id.
Dr. Constable examined Plaintiff on April 15, 2010. Tr. at 436. She administered a Euflexxa knee injection and indicated that Plaintiff may benefit from a partial knee replacement. Id. Plaintiff received additional Euflexxa injections on April 22 and 29, 2010. Tr. at 438-39.
Plaintiff complained of headaches to Dr. Varugheses on June 22, 2010, and Dr. Varugheses referred her for CT scan. Tr. at 490-94. CT of the head on June 23, 2010, was normal. Tr. at 441.
On July 8, 2010, state agency consultant James Haynes, M.D., completed a physical residual functional capacity assessment. Tr. at 443-50. Dr. Haynes indicated that Plaintiff was restricted as follows: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk about six hours in an eight-hour workday; sit about six hours in an eight-hour workday; push and/or pull unlimited; occasional climbing of ramp/stairs, balancing, stooping, kneeling, crouching, and crawling; never climbing ladder/rope/scaffolds; occasional overhead reaching with the right shoulder; and avoid concentrated exposure to hazards (machinery, heights, etc), fumes, odors, dusts, gases, poor ventilation, etc. Tr. at 444-47.
On August 13, 2010, Plaintiff presented to orthopedic surgeon Frank Voss, M.D. Tr. at 451-52. Plaintiff indicated that she experienced numbness in her left leg that went down the medial side of the leg to the ankle. Tr. at 451. Dr. Voss concluded that Plaintiff had mild degenerative changes and possible osteonecrosis of the femoral condyle. Tr. at 452. He did not recommend total knee replacement because of Plaintiff's age, size, and the fact that her knees were not bone-on-bone due to arthritis. Id. Dr. Voss recommended that Plaintiff wear a knee brace and lose 100 pounds or more. Id. He did note, however, that if Plaintiff had osteonecrosis of the medial femoral condyle, total knee arthroplasty may be the correct course of action. Id.
Plaintiff followed up with Dr. Constable on September 10, 2010, who indicated that she agreed with Dr. Voss. Tr. at 455. Dr. Constable indicated that Plaintiff "has significant difficulty maintaining a functional level of employment." Id. She specifically indicated that "her knees will limit her from any significant walking, squatting, stooping, or stair climbing type activities." Id. Plaintiff was instructed to return as needed. Id.
On October 14, 2010, Plaintiff complained of depression to Dr. Varugheses. Tr. at 502. Plaintiff indicated that she was having problems with debt collectors because of her inability to work and that she was upset because her son was recently arrested. Id. She endorsed symptoms that included difficulty sleeping, overeating, concentration problems, short temper, and crying all the time. Tr. at 502-03. Plaintiff requested medication for her depression. Tr. at 502. Dr. Varugheses prescribed Prozac. Tr. at 504.
On November 22, 2010, Dr. Constable completed a form for Plaintiff to obtain a disabled placard and license plate. Tr. at 473. Dr. Constable checked boxes that indicated that Plaintiff had "an inability to ordinarily walk one hundred feet nonstop without aggravating medical condition, including the increase of pain" and "an inability to ordinarily walk without the use of, or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device." Id. Dr. Constable also checked a box that indicated that the disability was permanent. Id.
Plaintiff followed up with Dr. Varugheses on November 30, 2010. Tr. at 506-09. Plaintiff reported increased blood pressure, but denied symptoms of depression. Tr. at 506.
On December 15, 2010, state agency consultant James Weston, M.D. completed a physical residual functional capacity assessment in which he indicated that Plaintiff was restricted as follows: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds, stand and/or walk (with normal breaks) for about six hours in an eight-hour workday; sit (with normal breaks) for about six hours in an eight-hour workday; occasionally push and/or pull with foot pedals using the left lower extremity; frequently balancing; occasionally climbing ramp/stairs, stooping, kneeling, crouching, and crawling; and never climbing ladder/rope/scaffolds. Tr. at 475-82.
On January 18, 2011, Plaintiff presented to Jandrette E. Rhoe, M.D., to establish treatment. Tr. at 569-70. Plaintiff complained of back and rib pain and blood in her urine, dysuria, and urinary frequency. Tr. at 569. Dr. Rhoe noted that Plaintiff had a limping gait and that she ambulated with a left knee brace. Tr. at 570.
Plaintiff followed up with Dr. Ewart on January 19, 2011. Tr. at 513-14. Plaintiff indicated that she experienced some improvement and was falling less when using the unloader brace prescribed by Dr. Constable. Tr. at 513. She complained of pain in her neck and shoulder. Id. Dr. Ewart observed painful range of motion of both the shoulder and neck and positive impingement test of the right shoulder. Id. Dr. Ewart recommended conservative treatment for the shoulder and neck. Tr. at 514.
Plaintiff followed up with Dr. Rhoe on April 18, 2011, with complaints of left knee pain, back pain, and itching. Tr. at 565-66. Dr. Rhoe noted that Plaintiff was depressed because she had limited movement and could not do the things she used to do. Tr. at 565. She was prescribed a cream for her rash and Amitriptyline for pain and referred to Dr. Rodgers for depression. Tr. at 566.
On May 31, 2011, Plaintiff complained to Dr. Rhoe that her knee pain was worsening. Tr. at 572. Plaintiff indicated that the pain in her left knee felt like bone-onbone. Id. Plaintiff complained of increased pain, swelling, and warmth in her right knee. Id.
On June 4, 2011, Plaintiff presented to the emergency room at Palmetto Health Richland after sustaining a fall while walking down stairs. Tr. at 519-61. X-ray of the right knee indicated only mild degenerative change in the medial compartment. Tr. at 535. X-ray of the left knee indicated moderate to severe two compartment degenerative change. Tr. at 536. X-ray of the lumbar spine showed no acute osseous injury. Tr. at 537. Plaintiff had limited active motion of the bilateral lower extremities. Tr. at 549.
Plaintiff followed up with Dr. Rhoe on June 16, 2011, for knee pain, back pain, and blood in her urine. Tr. at 563-64. Plaintiff's blood pressure medication was changed, but all other medications remained the same. Tr. at 564. Plaintiff was noted to be ambulating with a cane and to be non-insulin dependent. Id.
X-ray of the left knee on August 22, 2011, indicated left medial compartment and patellofemoral arthritis. Tr. at 576.
X-ray of the right shoulder on August 23, 2011, indicated mild narrowing of the AC joint. Tr. at 577.
On August 31, 2011, Dr. Rhoe wrote a letter on Plaintiff's behalf, which was addressed to the social security office. Tr. at 578. Dr. Rhoe indicated that Plaintiff had multiple knee surgeries and right shoulder surgery and that she suffered from severe degenerative arthritis in the knees that did not allow her to stand for any significant length of time and caused her considerable pain. Id. Dr. Rhoe wrote that Plaintiff was not a candidate for knee replacement and that her symptoms would only worsen. Id. She indicated that Plaintiff wore a left knee brace to avoid falls. Id. Finally, she wrote that Plaintiff "cannot work given her existing condition." Id. The record also contains an undated letter from Dr. Rhoe, which indicates that Plaintiff "has significant medical conditions that affect her ability to work." Tr. at 515. Dr. Rhoe noted many of the same impairments set forth above, but also noted that Plaintiff ambulated with a left metal knee brace and a cane. Id. Dr. Rhoe wrote that Plaintiff "suffers from pain issues as well as physical limitations." Id.
On September 15, 2011, Plaintiff presented to the emergency department at Palmetto Health Richland with complaint of rib pain after sustaining a fall. Tr. at 580-84. Plaintiff reported that she fell frequently, even when using her brace and cane. Tr. at 581. Plaintiff was noted to walk slowly with her cane and to be somewhat unsteady on her feet, but she was not observed to be in any pain when walking. Tr. at 582.
C. The Administrative ...