Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Godwin v. Colvin

United States District Court, D. South Carolina, Florence Division

September 29, 2016

SHERYL ELIZABETH GODWIN, Plaintiff,
v.
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.

          ORDER

          Thomas E. Rogers, III United States Magistrate Judge

         This is an action brought pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. Section 405(g), to obtain judicial review of a “final decision” of the Commissioner of Social Security, denying Plaintiff's claim for disability insurance benefits (DIB) and social security income (SSI). The only issues before the Court are whether the findings of fact are supported by substantial evidence and whether proper legal standards have been applied.

         I. RELEVANT BACKGROUND

         A. Procedural History

         Plaintiff filed an application for DIB and SSI on September 28, 2010, alleging inability to work since July 1, 2010. Her claims were denied initially and upon reconsideration. Thereafter, Plaintiff filed a request for a hearing. A hearing was held on June 25, 2011, at which time the Plaintiff and a vocational expert (VE) testified. The Administrative Law Judge (ALJ) issued an unfavorable decision on February 17, 2012, finding that Plaintiff was not disabled within the meaning of the Act. (Tr.10-19). Plaintiff filed a request for review of the ALJ's decision, which the Appeals Council denied on April 26, 2013, making the ALJ's decision the Commissioner's final decision. Plaintiff filed an action in this court on June 6, 2013. While her case was pending, Plaintiff filed a second application for DIB on July 20, 2013, which was consolidated with her original claim. The Commissioner requested that this court remand Plaintiff's claim so that the ALJ could clarify whether Plaintiff's back and feet/ankle impairments were severe for a 12-month consecutive period; give further consideration to Plaintiff's maximum residual functional capacity; further evaluate Plaintiff's subjective complaints including side effects from medication; and obtain vocational expert testimony if warranted by the expanded record to clarify the demands of Plaintiff's past relevant work and/or the effect of Plaintiff's limitations on Plaintiff's occupational base. (Tr. 570-71).

         The ALJ updated the medical records by obtaining a consultative psychological examination and gathering treatment records generated after the ALJ's first decision. (Tr. 808-1076). On November 20, 2014, the ALJ held an administrative hearing at which Plaintiff and a vocational expert testified. (Tr. 494-523). On February 27, 2015, the ALJ issued a decision finding Plaintiff not disabled. (Tr. 473-84).

         Plaintiff did not file exceptions to the ALJ's decision, and the Appeals Council declined to assume jurisdiction. Accordingly, the ALJ's February 27, 2015, decision became final on April 29, 2015, 61 days after the decision. (Tr. 471). See 20 C.F.R. §§ 404.984(d), 416.1484(d). Plaintiff filed the present action on May 8, 2015.

         B. Plaintiff's Background and Medical History

         1. Introductory Facts

         Plaintiff was born on November 23, 1961, and was 48 years old at the time of the alleged onset. (Tr. 131). Plaintiff completed her education through high school and has past relevant work experience as an office manager and a courthouse clerk. (Tr. 27, 516). Plaintiff alleges disability due to fibromyalgia and arthritis. (Tr. 122-30, 145, 157).

         2. Medical Records[1]

         Dr. J. Grant Taylor at Coastal Carolina Rheumatology treated the Plaintiff in October and November of 2002, for complaints of pain in her shoulders, arms, neck, and lower back. She complained of frequent night awakening and nonrestorative sleep, as well as exacerbation of pain with mild activities and weather changes. In October of 2002, she weighed 141 pounds. Upon examination, Dr. Taylor indicated that the Plaintiff had tenderness over both trapezius muscles, the lumbar and cervical paraspinal musculature, both biceps, and lateral epicondyles. Dr. Taylor felt that her symptoms suggested fibromyalgia. Dr. Taylor continued to treat the Plaintiff's symptoms of fibromyalgia in November of 2002, namely nonrestorative sleep due to pain, anxiety, and diffuse tenderness over her trapezius muscles, the cervical and lumbar paraspinal musculature, and over both greater trochanteric bursa. (Tr. 322-326)

         Dr. Frank Harper at East Cooper Rheumatology began treatment of the Plaintiff in December of 2002, when she saw him for a second opinion regarding the diffuse muscle pain she was experiencing throughout her body, as well as sleeplessness, stiffness, chronic anxiety, and loss of appetite with pain. After examining her, Dr. Harper found exquisite tenderness to her paracervical musculature, trapezius muscles, periscapular areas, especially the medial scapular borders, the upper and mid back, the lower back especially around L4-5 extending down into the sacroiliac joint and gluteal areas bilaterally, bilateral lateral hips, medial knees, anterior chest wall, and anterior-lateral elbows. He felt that she had typical fibromyalgia syndrome with 18 of 18 of the classical trigger points, significant associated anxiety. (Tr. 465-66).

         Through the first few months of 2003, the Plaintiff's condition remained much the same with Dr. Harper identifying trigger points at each visit. Her trigger points were so diffuse in February of 2003, that he could not consider trigger point injections. By April of 2003, there was some improvement in her pain, and she was sleeping better, but she continued to have diffuse trigger points. On June 6, 2003, she reported pain and stiffness with the small joints of her hands, especially after yard work. Dr. Harper still noted multiple diffuse trigger points, and saw some bony enlargement and puffiness in her hand joints bilaterally. He diagnosed mild osteoarthritis of the hands with fibromyalgia syndrome. By July of 2003, the Plaintiff reported worsening of fibromyalgia symptoms, and Dr. Harper felt that the were almost back to square one in regard to trigger points and severe pain. In October of 2003, Dr. Harper had her fibromyalgia symptoms almost in remission, but the medication that helped the fibromyalgia, Zyprexa, had caused tremendous weight gain. When the Plaintiff returned to Dr. Harper on December 5, 2003, she had multiple trigger points, and he had to discontinue Zyprexa because she had gained an enormous amount of weight. With the medication change, when she returned to Dr. Harper on December 30, 2003, she had marked worsening of the fibromyalgia symptoms with trigger points in her trapezius muscles, periscapular areas, upper, mid and low back, and both lateral hips, as well as tenderness to her paracervical musculature. (Tr. 450-64).

         Throughout the first half of 2004, the Plaintiff continued to suffer with diffuse pain with multiple trigger points. Dr. Harper indicated in July of 2004, that if she continued to gain weight on the Zyprexa, he would have to discontinue the drug, but previous attempts to do so had led to an exacerbation of the fibromyalgia symptoms. The Plaintiff continued treatment with Dr. Harper through 2004, and by March of 2005, she had voluntarily discontinued Zyprexa due to the large weight gain on that medication. She reported having increasing muscle pain and stiffness diffusely. She still had multiple tender trigger points. (Tr. 434-466).

         On April 29, 2005, Dr. Harper noted that the Plaintiff still had muscle pain, stiffness, and arthralgias of her hands. He found tender trigger points in the paracervical musculature, trapezius muscle, medial periscapular areas, lower back, and bilateral hips. Her hands had some puffiness in the joints. Dr. Harper felt that she was having problems from mild inflammatory osteoarthritis. Her condition remained much the same for 2005. On September 8, 2006, she reported that she had a cervical diskectomy for severe neck and shoulder discomfort, and after surgery, she had developed more severe muscle pain and stiffness in both upper and lower extremities, neck, lower back, and lateral hips. Dr. Harper identified multiple tender trigger points, and felt that she was experiencing worsening fibromyalgia symptoms associated with significant stress. (Tr. 426-433).

         Dr. Harper did not see the Plaintiff again until May of 2009, when the Plaintiff described gradual progression of worsening muscle pain and stiffness. Dr. Harper's examination revealed exquisite tenderness of the Plaintiff's left shoulder with restriction of abduction, exquisite tenderness of the posterior scapular area, medial scapular border, and superior scapular area. There was also mild rotator cuff tenderness and tenderness of the periscapular areas bilaterally and lateral hips bilaterally. Dr. Harper felt that she was extremely depressed and that her fibromyalgia was overlapping with anatomical joint pain and left shoulder disease. He gave her a tender point injection at the superior edge of the left scapula. In June of 2009, the Plaintiff reported some benefit from her new medication, Imipramine, but she still had multiple tender trigger points. (Tr. 422-425).

         Dr. Frank Harper examined the Plaintiff on December 11, 2009, for fibromyalgia, esophageal reflux, inflammatory osteoarthritis, status post cervical diskectomy C6-7, left rotator cuff tear status post left rotator cuff surgical decompression and repair, irritable bowel syndrome. During this exam, Dr. Harper indicated that the Plaintiff had developed exquisite pain subsequent to her rotator cuff surgery with a general worsening of fibromyalgia-related symptoms. He noted that she had tender points located in her paracervical musculature, the trapezius muscles bilaterally, the medial scapular borders, the lower back, gluteal and lateral hips bilaterally, with the exception of the left shoulder, with marked restriction of abduction to approximately ninety degrees, with exquisite tenderness around the shoulder, and exquisite tenderness of the medial scapular border and trapezius area. Dr. Harper also indicated that the Plaintiff was emotionally distraught and disappointed in her shoulder surgery outcome. Dr. Harper injected the tender point in her left trapezius area with Xylocaine and Depo-Medrol and increased her imipramine. On a prior visit before the left rotator cuff surgery, Dr. Harper had also found tender trigger points in the Plaintiff's paracervical musculature, trapezius muscle, medial periscapular areas, lower back and lateral hips bilaterally. She also had restricted range of motion in her left shoulder at that time, with exquisite tenderness of the rotator cuff area. Dr. Harper still found trigger points, despite the Plaintiff having good response to imipramine with a reduction in fibromyalgia symptoms overall. She continued to experience restless limbs in her arms and legs at night. When the Plaintiff returned to Dr. Harper on February 12, 2010, she continued to suffer from severe left shoulder pain, as well as tender points in her paracervical musculature, the bilateral trapezius muscles, the medial scapular borders, the lower back, and gluteal and lateral hips bilaterally. Dr. Harper again noted exquisite tenderness of the left posterior scapular area. Dr. Harper commented that the Plaintiff's condition was extremely complex, since she has elements of fibromyalgia, inflammatory arthritis, and adhesive capsulitis complicating the previous rotator cuff repair. He stated that she was markedly restricted and felt that the adhesive capsulitis was contributing substantially to pain down her anterior and posterior aspects of the shoulder, but he was clear that she has tender point phenomenon as well. He again injected the left shoulder in an effort to help with the pain. (Tr. 220-225).

         On May 21, 2010, when Dr. Harper examined the Plaintiff, he found that she had tenderness of the paracervical musculature, the trapezius muscles, the medial scapular border areas, the upper back, L1-L5 bilaterally in the lower back, and the gluteal and lateral hip areas bilaterally. There was exquisite tenderness of the medial scapular borders bilaterally, so he injected those areas with Xylocaine and Depo-Medrol. He counseled the Plaintiff on the importance of stress management and noted that she was under considerable stress at work. He felt that she ultimately might have to retire from work for medical reasons. When the Plaintiff returned to Dr. Harper on June 2, 2010, she complained of diffuse myalgias, particularly in her neck, shoulders, and upper back. She reported that she was having difficulty sleeping and difficulty functioning in the workplace. During his physical examination, Dr. Harper again indicated that the Plaintiff had tenderness in her paracervical musculature, trapezius muscles, medial scapular border areas, the upper back, the lower back L1-L5 bilaterally, and the gluteal and lateral hip areas bilaterally. During this visit, he suggested that the Plaintiff leave the workplace and file for social security benefits since she had failed numerous therapies and he was convinced that she would not be able to carry on in the workplace. In July of 2010, Dr. Harper stated that the Plaintiff still had tenderness to the same areas of her body, and she had exquisite tenderness of her lower back, L1-L5 on the right. When the Plaintiff returned to Dr. Harper on August 20, 2010, she had developed severe left heel pain, especially on weightbearing. She continued to complain of diffuse muscle pain, stiffness, and fatigue. She continued to experience tenderness in the same areas of her body, and Dr. Harper indicated exquisite tenderness of the left plantar heel pad. At this visit, Dr. Harper expressed serious concern about the Plaintiff's weight (205 pounds at this visit) since he felt that it was causing significant lower extremity problems, and he urged weight loss. He again felt that her pain and other symptoms stemmed from fibromyalgia and inflammatory osteoarthritis. (Tr. 210-218).

         When the Plaintiff returned to Dr. Harper on October 20, 2010, he found that she still had diffuse pain, stiffness, and fatigue with worsening bilateral heel pain. His examination of the Plaintiff once again showed multiple areas of tenderness. On December 29, 2010, Dr. Harper noted that the Plaintiff was experiencing substantial breakthrough pain after beginning chiropractic physiotherapy, as recommended by Dr. Harper in a previous visit. She still had tenderness to her paracervical musculature, the trapezius muscles, the medial scapular border areas, the upper back, the lower back L1-L5 bilaterally, and the gluteal and lateral hip areas bilaterally. Dr. Harper recommended continuation of the chiropractic physiotherapy and continued weight reduction, and he prescribed Hydrocodone for the severe breakthrough pain. (Tr.418-421).

         On February 24, 2011, Dr. Frank Harper examined the Plaintiff and indicated she had bilateral heel pain, as well as tenderness of the paracervical musculature, the trapezius muscles, the medial scapular border areas, the upper back, the lower back L1-L5 bilaterally, and gluteal and lateral hip areas bilaterally. He noted exquisite tenderness of the chest wall and four areas, including two symmetrically in the lower ribs and two symmetrically at the second intercostal space, midclavicular line bilaterally. The Plaintiff also reported a very upsetting recent disability exam that Dr. Harper felt contributed to her fibromyalgia flare. He also stated that her chest wall pain was severe enough to cause restriction of the chest wall movement. He prescribed Lidoderm patches for her pain and again strongly recommended weight loss due to her heel pain. On May 2, 2011, Dr. Harper opined that the Plaintiff suffered from depression and anxiety for which she was prescribed Xanax XR. He further felt that she had depressed mood/affect, poor concentration and memory, and she had obvious work-related limitation of function due to her mental condition. (Tr. 276-278).

         On May 5, 2011, Dr. Frank Harper noted that the Plaintiff continued to experience diffuse muscle pain, stiffness, bilateral plantar heel pain, and right shoulder pain with abduction and extension. During the examination, Dr. Harper found tenderness of the paracervical musculature, the trapezius muscles, the medial scapular border areas, the upper back, the lower back L1-L5 bilaterally, and gluteal and lateral hip areas bilaterally. Dr. Harper indicated that the Plaintiff had exquisite tenderness of the posterior aspect of the right rotator cuff area and tenderness of the bilateral plantar heels. He again urged the Plaintiff to lose weight to help with her heel pain, he prescribed Xanax for fibromyalgia-related symptoms, and he injected her right shoulder with a combination of Xylocaine and Depo-Medrol. Dr. Harper treated the Plaintiff on July 21, 2011, for muscle pain, stiffness, and fatigue. At that time, the Plaintiff said that she had lost eleven pounds since her previous visit, but her low back pain had continued to be severe. After finding tenderness to the Plaintiff's paracervical musculature, the trapezius muscles, the medial scapular border areas, the upper back, the lower back from L1 to L5 bilaterally, the bilateral gluteal and lateral hip areas, and especially exquisite tenderness at ¶ 4-5 bilaterally, Dr. Harper injected two tender points in the Plaintiff's lower back with Xylocaine and Depo-Medrol. (Tr. 316-317, 416-417).

         On September 30, 2011, the Plaintiff reported to Dr. Harper that she had been receiving epidural steroid injections from Dr. Poletti for increasing low back pain. She also reported continued muscle pain, stiffness, and persistent fatigue. Dr. Harper again found tenderness in multiple body areas, noting exquisite tenderness of her left lateral hip and flank. Dr. Harper indicated that the Plaintiff's fibromyalgia was complicating the nerve root compression at ¶ 4-5. The Plaintiff had continued to lose weight, which he felt would ultimately help her back pain. (Tr. 412-413).

         The Plaintiff was again examined by Dr. Harper on November 22, 2011, at which time she reported persistent myalgias, stiffness and fatigue, bilateral medial knee pain that was difficult to tolerate, and restless sleep at night. Dr. Harper noted that there was tenderness of the paracervical musculature, trapezius muscles, medial scapular areas, the upper back, the lower back L1 to L5 bilaterally, and gluteal and lateral hip areas bilaterally. Dr. Harper also described exquisite tenderness of the medial knees bilaterally, and he stated that she had notorious difficulty tolerating drug therapies in the past. He felt that her medial knee pain was typical of fibromyalgia. When the Plaintiff returned to Dr. Harper on January 26, 2012, she reported continued excruciating medial knee pain, as well as restriction of activity and diffuse myalgias, stiffness, and fatigue. Dr. Harper found tenderness to the same areas that he found in November of 2011, and he indicated exquisite tenderness of the anserine bursa of the right knee. He felt that the Plaintiff had an element of osteoarthritis of the knees. He stated that the Plaintiff's fibromyalgia was prominent with significant chronic fatigue. She had also experienced weight gain. Dr. Harper recognized that the Plaintiff was under the care of Dr. Stephen Poletti for neck pain. Dr. Harper injected the Plaintiff's right knee with Xylocaine and Depo-Medrol. On March 28, 2012, when Dr. Harper once again examined the Plaintiff, she reported that an increase in Xanax to twice daily seemed to be beneficial, she continued to have diffuse myalgias, persistent left lateral hip pain, and a worsening of right knee pain. Her tender points remained consistent with the examinations from November 2011, and January 2012, and Dr. Harper described exquisite tenderness of the left lateral hip and right knee anserine bursa. Dr. Harper also counseled the Plaintiff since she was distraught during his examination, particularly over her traumatic disability hearing and subsequent denial. Dr. Harper reiterated that the Plaintiff had active fibromyalgia, inflammatory osteoarthritis, and recurring right anserine bursitis. Dr. Harper increased the Plaintiff's Xanax to twice daily and prescribed a Prednisone Dosepak. In May of 2012, the Plaintiff told Dr. Harper that her symptoms of pain, stiffness and fatigue were unimproved, and she continued to have worsening right knee pain and intermittent right elbow pain. She had also gained more weight. On July 18, 2012, the Plaintiff indicated that there had been no improvement in her symptoms, other than a three-pound weight loss. Dr. Harper's examination revealed the same tender points, and he stated that ultrasound images confirmed likely osteoarthritis of the right knee compatible with recurring medial knee pain, most likely anserine bursitis. (Tr. 916-924).

         On October 17, 2012, when Dr. Harper examined the Plaintiff, she had recently been released from her hospitalization, and Dr. Harper noted that she had lost 23 pounds and subsequent to her hospitalization, she had a severe flare of fibromyalgia and migraine headaches. On December 19, 2012, the Plaintiff's condition had not improved, and she had developed abdominal problems and a fistula. Dr. Harper was concerned that she had inflammatory bowel disease with associated fistula. Dr. Harper noted on March 27, 2013, that the Plaintiff had continued right elbow and arm pain, lateral hip pain bilaterally, the same multiple tender points, restricted range of motion of the right shoulder, and exquisite tenderness of the tender point in the distal triceps ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.