United States District Court, D. South Carolina
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 Civ. 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 April 9, 2012, Plaintiff protectively filed applications for DIB and SSI in which she alleged her disability began on January 30, 2010. Tr. at 82, 83. Her applications were denied initially and upon reconsideration. Tr. at 120-24, 129-30, 131-32. On November 6, 2013, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Kelly Wilson. Tr. at 47-81 (Hr'g Tr.). The ALJ issued an unfavorable decision on December 16, 2013, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 25-44. 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 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on April 28, 2015. [ECF No. 1].
B. Plaintiff's Background and Medical History
Plaintiff was 45 years old at the time of the hearing. Tr. at 55. She completed high school. Tr. at 109. Her past relevant work ("PRW") was as a hair stylist and a call center operator. Tr. at 79. She alleges she has been unable to work since January 30, 2010. Tr. at 82, 83.
2. Medical History
On March 21, 2011, Plaintiff presented to Fredric Woriax, M.D. ("Dr. Woriax"), to establish treatment. Tr. at 255. She complained of high blood pressure, and her blood pressure was elevated at 184/108. Tr. at 255-56. She was 50 inches tall, weighed 202.6 pounds, and had a body mass index ("BMI") of 39.6 kg/m2. Tr. at 256. She demonstrated no dysfunction on motor examination, and Dr. Woriax noted no abnormalities on physical examination. Tr. at 256-57. Dr. Woriax assessed malignant essential hypertension and dysmetabolic syndrome X. Tr. at 257.
Plaintiff presented to Cherise Fretwell, APRN ("Ms. Fretwell"), for a blood pressure check and medication refills on October 13, 2011. Tr. at 253. She complained of pain in her lower back and bilateral knees and difficulty with ambulation. Id. Ms. Fretwell observed edema, tenderness to palpation, and pain with motion of Plaintiff's bilateral knees. Tr. at 254. She prescribed Diclofenac Sodium and instructed Plaintiff to follow up in three months. Tr. at 255.
Plaintiff presented to Catherine Toomer, M.D. ("Dr. Toomer"), on February 1, 2012, with ongoing and worsening knee pain. Tr. at 252. Dr. Toomer observed Plaintiff to have swelling, tenderness, abnormal motion, crepitus, and pain with motion of her knees. Id. She indicated Plaintiff had an abnormal gait and demonstrated a limp. Id. She referred Plaintiff for x-rays of both knees. Tr. at 253.
On February 22, 2012, Plaintiff presented to Dr. Toomer, to discuss x-ray results. Tr. at 250. She indicated she was experiencing bilateral knee pain and swelling that was worsened by weight-bearing and extended activity. Id. Dr. Toomer observed Plaintiff to have swelling, tenderness on palpation, and pain with motion. Tr. at 251. She referred Plaintiff for magnetic resonance imaging ("MRI") of her knees. Id.
Plaintiff underwent MRIs of her bilateral knees on March 20, 2012. Tr. at 266-67. The MRI of Plaintiff's right knee showed severe chronic degenerative changes of all three compartments and a grossly abnormal medial meniscus that suggested chronic degenerative change with acute superimposed bucket-handle tear. Tr. at 266. The MRI of Plaintiff's left knee indicated severe degenerative changes that were complicated by chondral injury at the medial compartment, complete loss of the medial meniscus, and oblique tear of the anterior lateral meniscus. Tr. at 267.
On May 1, 2012, Plaintiff presented to Kevin Ard, PA-C ("Mr. Ard"), with complaints of numbness in her right thigh and pain in her back, bilateral knees, and right thigh. Tr. at 264. She indicated she did a lot of bending and spent a lot of time on her feet. Id. She denied weakness and swelling. Id. X-rays indicated severe degenerative changes to the medial compartments of Plaintiff's bilateral knees with spurring. Tr. at 263. Mr. Ard indicated Plaintiff walked with a normal gait. Tr. at 264. He observed Plaintiff to have areas of tenderness to the medial aspects of both knees, but to have no obvious edema or effusion. Id. Plaintiff demonstrated normal range of motion ("ROM") to both knees and good strength in her lower extremities. Id. She was 4' 11" tall and weighed 198 pounds. Id. Mr. Ard noted Plaintiff had no tenderness in her lumbar spine, and a straightleg raising test was negative. Id. He indicated that Plaintiff was most likely to benefit from an injection to her knees, but Plaintiff declined the injection. Id.
Plaintiff presented to Ty W. Carter, M.D. ("Dr. Carter"), on May 29, 2012, for an orthopedic follow up visit. Tr. at 303. Plaintiff complained of intermittent pain in her back and numbness in her right anterior thigh. Id. Dr. Carter observed Plaintiff to have no tenderness in her lumbar spine; full ROM of all her joints and her back; no redness, swelling, or warmth; no decreased sensation in her lower extremities; and good strength throughout. Id. An x-ray showed mild narrowing of the L5-S1 disc space, but no other abnormalities. Id. Dr. Carter indicated he would treat Plaintiff conservatively with Mobic and that Plaintiff may benefit from an MRI of her lumbar spine. Id.
Plaintiff followed up with Dr. Toomer to have her pain medication refilled on June 19, 2012. Tr. at 275. She weighed 199.1 pounds and had a BMI of 38.9 kg/m2. Tr. at 276. Dr. Toomer indicated Plaintiff's knee was tender to palpation on ambulation and that Plaintiff complained of pain with motion of her knee. Id. However, she observed no edema, erythema, warmth, induration, or dislocation of the knee. Id. She noted Plaintiff's gait was abnormal and observed Plaintiff to be limping. Id.
On June 25, 2012, state agency medical consultant Rebecca Meriwether, M.D., completed a physical residual functional capacity ("RFC") evaluation and found that Plaintiff could perform work with the following limitations: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk for a total of two hours during an eight-hour workday; sit for a total of about six hours in an eight-hour workday; occasionally climbing ramps/stairs, balancing, stooping, and kneeling; and never climbing ladders/ropes/scaffolds, crouching, or crawling. Tr. at 88-90. Darla Mullaney, M.D., assessed the same limitations on September 26, 2012. Tr. at 106-08.
On August 21, 2012, Plaintiff presented to Dr. Toomer for medication refills and requested that Dr. Toomer complete disability paperwork. Tr. at 274. Plaintiff complained that her knee pain caused her difficulty with standing, walking, and sleeping. Id. She reported knee joint pain and swelling and indicated her knee had a clicking sensation and would lock up suddenly. Id. Dr. Toomer observed tenderness to palpation and pain with motion of the knee, but noted no edema or erythema. Id. She diagnosed osteoarthrosis of the knee and chronic pain. Tr. at 275.
Plaintiff presented to Gary Fischbach, M.D. ("Dr. Fischbach"), on October 5, 2012. Tr. at 284. She indicated that Dr. Toomer had not filled out disability paperwork and requested that Dr. Fischbach complete it. Id. Dr. Fischbach noted that Plaintiff was instructed to discontinue use of a strap-on stabilizing knee brace because the course of treatment was completed. Id. He indicated Plaintiff weighed 202.2 pounds and had a BMI of 39.5 kg/m2. Id. Dr. Fischbach informed Plaintiff that he could not complete the disability paperwork because it would require a functional capacity evaluation ("FCE"). Id. He suggested Plaintiff's attorney contact Hitchcock Rehabilitation to determine if they still performed FCEs. Id.
On November 16, 2012, Plaintiff complained to Dr. Fischbach of pain in her bilateral knees. Tr. at 291. She weighed 204.1 pounds and had a BMI of 39.9 kg/m2. Id. Dr. Fischbach noted no abnormalities. Tr. at 291-92. He refilled Plaintiff's medications and instructed her to follow up in three months. Tr. at 292.
On December 10, 2012, Plaintiff indicated to Dr. Carter that her back was doing well, but that she continued to experience bilateral knee pain. Tr. at 302. She requested that Dr. Carter prescribe Tylenol with Codeine and stated that Dr. Fischbach had indicated he would no longer prescribe pain medications. Id. Dr. Carter indicated Plaintiff was not a good candidate for total knee arthroplasty and did not want injections, surgery, or a knee brace. Id. He noted that Plaintiff only wanted for her pain medications to be refilled. Id. He informed Plaintiff that he did not treat long-term pain and that she would need to follow up with a pain management physician. Id. He prescribed Tramadol and told Plaintiff that she could return to the office if she decided to pursue knee injections or potential surgery. Id.
Plaintiff followed up with Dr. Carter on March 8, 2013. Tr. at 301. She complained of back pain and worsening knee pain. Id. Dr. Carter indicated he did not feel that Plaintiff needed knee replacement at that time because she was only 43-years-old. Id. He stated Plaintiff could benefit from arthroscopy and referred her to Dr. Holford for a consultation. Id. He instructed Plaintiff to follow up with Dr. Fischbach for pain management. Id.
Plaintiff followed up with Dr. Fischbach on April 5, 2013, for routine care and medication refills. Tr. at 289. She indicated that the orthopedist had told her that she had no cartilage in her knees, but was too young for knee replacement. Id. Plaintiff weighed 194 pounds and her BMI was 37.9 kg/m2. Id. Dr. Fischbach noted no abnormalities on examination. Tr. at 289-90. He discontinued Tylenol with Codeine and prescribed Tramadol four times daily, as needed for pain. Tr. at 290.
Plaintiff presented to Douglas E. Holford, M.D. ("Dr. Holford"), for further evaluation of knee pain on March 11, 2013. Tr. at 299. Dr. Holford noted that Plaintiff was 4' 11" tall and weighed 195 pounds. Id. He indicated Plaintiff had three to 75 degrees of flexion and tenderness along her medial joint line. Id. He observed crepitation of the medial compartment and the undersurface of the patella. Id. He stated x-rays showed bone-on-bone involvement of the medial joints and marked osteophyte formation around the posterior aspect of Plaintiff's bilateral knees. Id. He indicated Plaintiff also had early degenerative joint disease of the lateral joints. Id. Dr. Holford discussed Orthovisc knee injections with Plaintiff, but he indicated they would not give her much benefit because her knees were bone-on-bone. Id. He stated "I think she will qualify for disability under 2 major weightbearing joints, prolonged standing, et cetera." Id.
Plaintiff followed up with Dr. Holford on July 10, 2013. Tr. at 296-98. Plaintiff rated her pain as a six out of ten and indicated it was aggravated by weight-bearing, walking, running, climbing stairs, bending, movement, and prolonged sitting. Tr. at 296. Dr. Holford noted that Plaintiff was 4' 11" tall and weighed 185 pounds. Id. He indicated Plaintiff's left knee was tender to palpation at the medial joint space line, but had full ROM and normal stability. Tr. at 297. He observed Plaintiff's right knee to be tender to palpation at the medial joint space line and popliteal fossa, but to have 5/5 strength and normal stability. Id.
On July 12, 2013, Plaintiff presented to Dr. Fischbach for routine care and medication refills. Tr. at 307. She indicated that she felt "ok." Id. She weighed 180.2 pounds and had a BMI of 35.2 kg/m2. Id. Dr. Fischbach described Plaintiff's musculoskeletal exam as "normal." Id. He refilled Plaintiff's prescriptions for Tramadol for pain, Meloxicam for arthritis, and Hydrochlorothiazide-Lisinopril for hypertension. Tr. at 308.
C. The Administrative Proceedings
1. The Administrative Hearing
a. Plaintiff's Testimony
At the hearing on November 6, 2013, Plaintiff testified she last worked as a telemarketer in 2010. Tr. at 55. She stated she was laid off from her job and collected unemployment compensation until 2012. Tr. at 57. She indicated she applied for jobs during the time that she was collecting unemployment. Id.
Plaintiff testified she was treated by Dr. Holford. Tr. at 61. She indicated that both Dr. Holford and Dr. Carter had recommended she undergo injections to both knees, but that she refused because of a fear of needles and the particular length and thickness of the needles that would be used to administer the injections. Id. She testified she had declined arthroscopic surgery because Dr. Holford indicated it would not help her pain. Tr. at 62-63. She stated Dr. Holford indicated she was not a candidate for knee replacement because she was under age 50. Id.
Plaintiff testified she had arthritis in her lower back that caused her to experience pain and numbness in her thighs and feet. Tr. at 64. She stated that she had weighed as much as 300 pounds, but had lost around 100 pounds over the prior two-year period. Tr. at 65. She indicated she had attempted to lose weight because her doctors had suggested it would help her knee problems, but that her knee pain had only increased. Id. She stated she had weighed 182 or 183 pounds at her last doctor's visit. Id.
Plaintiff indicated she started using a walker at the beginning of the year. Tr. at 69. She stated she had to rest more frequently while walking to and from her daughter's bus stop before she started using the walker. Id. She indicated she could lean on her walker if there was nowhere for her to sit. Id. She testified that she used a cane before she started using the walker. Id. Plaintiff denied that a cane or walker had been prescribed by her physicians, but stated that Dr. Carter had told her that she may need a device for support and stability. Id. She indicated she typically either used a cane or held on to the wall or furniture when moving about her house. Tr. at 70.
Plaintiff testified that her pain necessitated that she elevate her legs after being out for about an hour. Tr. at 58. She stated she could sit for five to 10 minutes before her feet went numb. Tr. at 64. She testified she also experienced numbness in her hands. Id.
Plaintiff testified that she lived in her mother's house. Tr. at 66. She indicated her mother was retired and had recently been diagnosed with cancer. Tr. at 66-67. She stated she had an eight- and a 14-year-old daughter who lived with her. Tr. at 66. She indicated she had never had a driver's license because she had lived in Chicago and relied on public transit. Tr. at 67. She stated she could dress herself, but had to sit to dress. Tr. at 67-68. She testified that her oldest daughter did most of the household chores and that her mother was able to care for her own needs. Tr. at 68. She indicated that she spent most of a typical day either lying in bed or sitting in a chair with her legs elevated. Tr. at 71. She testified that she read the newspaper and watched television. Tr. at 72. She stated her sisters sometimes shopped for her groceries and indicated that she used a motorized cart if she went to the grocery store. Tr. at 71. She indicated she attended church, but sat close to the bathroom and was up and down during the service. Tr. at 74.
Plaintiff testified she was prescribed Meloxicam for arthritis and Tramadol for pain. Tr. at 59. She stated the only side effects she experienced from her medications were dry mouth and thirst. Tr. at 60. She indicated she had worn bilateral knee braces since 2011. Tr. at 74.
b. Vocational Expert Testimony
Vocational Expert ("VE") Benson Hecker reviewed the record and testified at the hearing. Tr. at 78-80. The VE categorized Plaintiff's PRW as a hair stylist, Dictionary of Occupational Titles (" DOT ") number 332.271-018, as light with a specific vocational preparation ("SVP") of six and a phone call center operator, DOT number 332.271-018, as sedentary with an SVP of four. Tr. at 79. The ALJ described a hypothetical individual of Plaintiff's vocational profile who could perform sedentary work with the following restrictions: no pushing or pulling with the lower extremities; occasionally balancing, stooping, kneeling, and climbing ramps and stairs; and no crouching, crawling, or climbing ladders, ropes, or scaffolds. Id. The VE testified that the hypothetical individual could perform Plaintiff's PRW as a call center operator. Id. The ALJ asked the VE to assume the same restrictions in the first hypothetical question, but to further assume the individual would need to elevate ...