United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. HODGES COLUMBIA, SOUTH CAROLINA UNITED STATES MAGISTRATE
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”). 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 reversed
and remanded for further proceedings as set forth herein.
12, 2014, Plaintiff protectively filed an application for
in which she alleged her disability began on May 21, 2012.
Tr. at 70 and 170-73. Her application was denied initially
and upon reconsideration. Tr. at 103-06 and 112-17. On March
22, 2016, Plaintiff had a hearing before Administrative Law
Judge (“ALJ”) John T. Molleur. Tr. at 35-69
(Hr'g Tr.). The ALJ issued an unfavorable decision on May
4, 2016, finding that Plaintiff was not disabled within the
meaning of the Act. Tr. at 18-34. 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 1-5. Thereafter,
Plaintiff brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on April 27,
2017. [ECF No. 1].
Plaintiff's Background and Medical History
was 52 years old at the time of the hearing. Tr. at 42. She
completed high school and some college, but did not obtain a
degree. Id. Her past relevant work
(“PRW”) was as an administrative assistant. Tr.
at 62. She alleges she has been unable to work since May 21,
2012. Tr. at 170.
initiated treatment with rheumatologist Clarence W. Legerton,
M.D. (“Dr. Legerton”), on June 1, 2011. Tr. at
351. She reported that she had been diagnosed with
fibromyalgia in 1991 and that her pain had worsened over the
prior three- to four-month period, resulting in poor sleep,
low energy, weight gain, and depressed mood. Id. Dr.
Legerton observed Plaintiff to be morbidly obese. Tr. at 352.
He noted the presence of 18 of 18 fibromyalgia tender points.
Id. He referred Plaintiff for lab work, prescribed
Trazodone and Neurontin, continued Cymbalta, and instructed
Plaintiff to walk for exercise. Tr. at 353 and 355.
presented to Industrial Medical Center on August 8, 2011,
after sustaining a three-foot fall from a chair onto the
floor and injuring her lower back and tailbone. Tr. at 329.
Marcus Schaefer, M.D. (“Dr. Schaefer”), assessed
strains to Plaintiff's lumbosacral and thoracic spine.
Id. He referred Plaintiff to physical therapy and
prescribed ibuprofen and Skelaxin. Id.
presented to the emergency room (“ER”) at Moncks
Corner Medical Center the next day with complaints of a
headache and severe neck pain. Tr. at 333. Susan M. Smith,
M.D. (“Dr. Smith”), described Plaintiff as
“in severe distress” and noted decreased range of
motion (“ROM”) of the neck; moderate soft tissue
tenderness throughout the neck; limited ROM of the back; and
moderate tenderness throughout the lumbar spine. Tr. at
333-34. X-rays of Plaintiff's lumbosacral spine showed
mild degenerative disc disease at ¶ 4-5 and L5-S1, but
x-rays of her cervical spine were normal. Tr. at 334. Dr.
Smith assessed lumbar strain and contusion, acute cervical
strain, hypertension, and contusion to the coccyx.
Id. She prescribed Zofran, Percocet, and Phenergan
and instructed Plaintiff to follow up with her doctor in
three days if she failed to improve. Tr. at 335-36.
presented to Doctors Care on August 11, 2011, and reported
pain in her sacrum and paraspinous muscles. Tr. at 366. The
attending physician assessed a tailbone contusion and a
lumbar strain and administered a Toradol injection.
returned to Doctors Care on August 15, 2011, for neck pain.
Tr. at 370. She reported lightheadedness that occurred when
she turned to the right and indicated she was afraid to
drive. Id. An x-ray of Plaintiff's cervical
spine was negative. Id. She had 5/5 neck strength
and full ROM. Id. The provider instructed Plaintiff
to continue taking Naproxen and Skelaxin and to take Flexeril
only at night. Id.
presented to Sandra Brehmer, FNP (“Ms. Brehmer”),
on August 16, 2011, with complaints of back and neck pain.
Tr. at 425. She described pain in her tailbone that radiated
to her low back and was exacerbated by sitting. Id.
She indicated she would experience a “flash” of
pain in her neck if she turned it too quickly. Id.
Ms. Brehmer observed Plaintiff to appear agitated and in
pain. Tr. at 426. She noted restricted ROM in Plaintiff's
lumbar and cervical spine. Id.
underwent magnetic resonance imaging (“MRI”) of
her cervical and lumbar spine the same day. Tr. at 402-05.
The MRI of her cervical spine showed no severe stenosis, but
“scattered mild interspinous ligament edema in the
upper and lower cervical spine, possibly due to ligamentous
strain or sprain” and mild mid-cervical spondylosis
that was most-evident at ¶ 5-6, “where there might
be slight contact exiting C6s by foraminal disc osteophyte
complexes.” Tr. at 402. The MRI of her lumbar spine
indicated mild degenerative disc disease and mild-to-moderate
facet arthropathy that was most pronounced at ¶ 3-4
through L5-S1, but no significant stenosis, definite neural
contact, or acute fracture. Tr. at 404.
returned to Dr. Legerton on August 17, 2011, and reported
that she had recently sustained a fall that had caused pain
in her buttocks, back, and neck. Tr. at 349. She indicated
she was having a “bad fibro day, ” but stated it
was the first one in three weeks. Id. She reported
she was no longer taking Cymbalta, but that her mood was
better and her affect was “not as flat.”
Id. Dr. Legerton observed Plaintiff to be very
tender in her spine and back and diffusely tender in the
fibromyalgia tender points. Id. He noted that
Plaintiff was “actually doing well” and continued
her on her same medications. Id.
initiated physical therapy for her lumbar spine on August 18,
2011. Tr. at 518. She reported a high level of pain and was
unwilling to perform multiple exercises. Tr. at 519. The
physical therapist recommended that Plaintiff be seen twice a
week for four weeks. Tr. at 520. Plaintiff received
subsequent authorization for additional visits. Tr. at
followed up at Doctors Care on August 25, 2011. Tr. at 374.
She complained of low back pain that woke her during the
night, but indicated her tailbone was no longer hurting.
Id. The provider noted that Plaintiff was moving
slowly and was unwilling to sit. Id. He prescribed
ibuprofen, Skelaxin, and Trazodone and instructed Plaintiff
to continue physical therapy and follow up with a
presented to neurosurgeon Joseph M. Marzluff, M.D.
(“Dr. Marzluff”), for evaluation of neck and back
pain on August 31, 2011. Tr. at 341-42. She reported a
history of fibromyalgia, but indicated the new-onset pain was
different. Tr. at 341. She described her back pain as
primarily axial and endorsed pain in the back of her neck
that occasionally radiated into her head and right arm.
Id. Dr. Marzluff observed Plaintiff to have
restricted ROM of the neck and back in all directions.
Id. He indicated that straight-leg raising
(“SLR”) at 90 degrees reproduced Plaintiff's
back pain, but did not cause radicular pain. Id. He
observed no motor, sensory, or reflex abnormality.
Id. He stated Plaintiff's symptoms were
consistent with cervical and lumbar strain with exacerbation
of preexisting degenerative disc disease. Id. Dr.
Marzluff indicated Plaintiff did not require surgical
intervention. Tr. at 342. He referred her to a pain
management physician. Id.
presented to Summar Phillips, M.D. (“Dr.
Phillips”), for an initial pain management evaluation
on September 8, 2011. Tr. at 392. She described her neck pain
as radiating into the base of her skull and her back pain as
radiating across her back and into her left hip, buttock,
thigh, and knee. Id. She indicated her pain was
exacerbated by turning her head, driving, reading, performing
household chores, and typing. Id. Dr. Phillips noted
the following abnormalities on examination: tenderness,
paraspinous spasm, pain with ROM, and limited flexion,
extension, bilateral rotation of the neck; antalgic gait;
decreased sensation to the right lower extremity; pain with
ROM and paraspinous tenderness in the lumbar spine and
sacroiliac (“SI”) joint; painful SLR test on the
right; inability to heel and toe walk; bilateral trochanteric
bursa tenderness; and pain with ROM of the right hip. Tr. at
394. She assessed cervicalgia, muscle spasm, back pain,
radicular syndrome of the lower limbs, radicular syndrome of
the upper limbs, spinal stenosis of the lumbar region,
degenerative disc disease of the lumbosacral spine,
degenerative disc disease of the cervical spine, and facet
arthropathy. Id. She discontinued ibuprofen and
Flexeril, prescribed Valium and Mobic, and instructed
Plaintiff to continue physical therapy. Id. She
indicated she would schedule Plaintiff for a cervical
epidural steroid injection (“ESI”). Id.
September 11, 2011, Plaintiff complained of paresthesias in
her left leg, radicular pain in her right leg, bilateral
trapezius pain, and headache. Tr. at 379. She indicated that
a transcutaneous nerve stimulation (“TENS”) unit
had worsened her pain and that physical therapy was providing
no relief. Id. The provider authorized additional
physical therapy sessions and prescribed Lortab. Id.
Phillips administered a cervical ESI at ¶ 5-6 on
September 20, 2011. Tr. at 395-96. On September 24, 2011,
Plaintiff reported her cervical ROM had slightly improved.
Tr. at 383. She indicated she felt better overall, but
continued to have some bad days. Id. The provider
indicated Plaintiff should continue to work with restrictions
for three hours per day, but anticipated that she would be
able to increase her work hours at her next visit. Tr. at
October 6, 2011, Plaintiff reported that her symptoms had
improved during the prior week, but had subsequently
worsened. Tr. at 387. She stated she was unable to tolerate
any position for longer than 15 to 20 minutes and could not
stand for longer than five minutes at a time. Id.
The provider referred Plaintiff for additional physical
therapy sessions. Id.
October 17, 2011, Plaintiff reported that she had
discontinued Valium and Mobic on her own because they had
been ineffective and had caused side effects. Tr. at 397. She
indicated she had restarted ibuprofen and Flexeril.
Id. She stated the cervical ESI had allowed her to
perform her normal activities in less pain, but continued to
report difficulty reading and performing her job. Tr. at 397
and 398. Dr. Phillips observed Plaintiff to have pain with
flexion, extension, and bilateral rotation of the neck,
paraspinous spasms, and tenderness to the trapezius muscle,
but she indicated Plaintiff's ROM was slightly improved.
Tr. at 397. Dr. Phillips referred Plaintiff to physical
therapy for her neck and indicated she would schedule a
second cervical ESI. Tr. at 398. She administered a second
ESI at Plaintiff's C5-6 level on October 25, 2011. Tr. at
presented to orthopedic surgeon James K. Aymond, M.D.
(“Dr. Aymond”), for an initial evaluation on
November 11, 2011. Tr. at 450. She reported pain in her
interscapular area and posterior neck and dysesthesias in her
left upper extremity. Id. She endorsed some lower
back pain, but indicated it had improved since her injury.
Id. Dr. Aymond observed Plaintiff to walk with a
normal heel-to-toe gait and to be able to heel and toe walk
without difficulty. Tr. at 451. He noted slightly reduced
deep tendon reflexes in the biceps, brachioradialis, and
triceps tendons and a slightly diminished sensory examination
in the C6 dermatome distribution bilaterally. Id.
Plaintiff had normal sensation in her lower extremities and
no radicular pain with SLR test. Id. Dr. Aymond
diagnosed lumbar strain and contusion and cervical
hyperflexion injury with cervical disc protrusion and
uncovertebral joint hypertrophy at the C5-6 level with
symptomatic neck pain and upper extremity dysesthesias.
Id. He recommended Plaintiff participate in
additional physical therapy for her neck and remain on
limited duty at work. Tr. at 451 and 529.
January 13, 2012, Dr. Aymond observed Plaintiff to have
limited ROM in the cervical and lumbar spine, but normal
motor and sensory examinations. Tr. at 452. He ordered
additional physical therapy sessions for Plaintiff's low
continued to report pain in her bilateral buttocks, low back,
and posterior neck on February 17, 2012. Tr. at 455. Dr.
Aymond observed limited ROM of the lumbar and cervical spine
and pain in the low back and bilateral buttocks on SLR test,
but indicated Plaintiff's neurological exam was normal.
Id. He recommended Plaintiff obtain an updated MRI
underwent a second MRI of the lumbar spine on March 12, 2012.
Tr. at 406. It indicated mild-to-moderate facet arthropathy
that was greatest at ¶ 5-S1, as well as mild
degenerative disc changes without disc herniation or
April 11, 2012, Dr. Aymond noted that the recent MRI of
Plaintiff's lumbar spine showed slight disc desiccation
at ¶ 4-5 and L5-S1 with no evidence of disc bulge or
herniation. Tr. at 457. He noted that Plaintiff had limited
flexion and extension of the lumbar spine and was tender over
the midline of the lower lumbar spine and the paraspinous
muscles. Id. He indicated SLR testing produced low
back pain. Id. He prescribed Lortab, Skelaxin, and
Motrin and recommended that Plaintiff undergo two lumbar
ESIs. Id. He indicated Plaintiff would be limited to
lifting 20 pounds or less and should avoid bending, twisting,
and sitting in elevated chairs. Tr. at 458 and 459.
presented to orthopedic surgeon Donald R. Johnson, II, M.D.
(“Dr. Johnson”), for an independent medical
evaluation (“IME”) on April 30, 2012. Tr. at 412-
13. She complained of low back pain and neck pain that
radiated through her upper shoulders and into her right arm.
Tr. at 412. Dr. Johnson indicated a cervical MRI showed
multilevel degenerative changes and foraminal disc and bone
spur complexes that contacted the exiting nerve roots.
Id. He stated the lumbar MRI showed facet
arthropathy and degenerative changes at ¶ 3-4, L4-5, and
L5-S1, but no disc herniation or stenosis. Id.
Plaintiff described her pain as a five on a 10-point scale
and indicated it was exacerbated by sitting and looking down.
Id. Dr. Johnson observed Plaintiff to be
5'3” tall and to weigh 260 pounds. Tr. at 413. He
noted that Plaintiff was diffusely tender in the midline, had
limited ROM of her neck and low back, and reported pain with
extension of her arm at the shoulder. Id. His
impressions were cervical spondylosis with stenosis most
pronounced at ¶ 5-6 and degenerative disc disease at
¶ 3-4, L4-5, and L5-S1. Id. He recommended that
Plaintiff obtain an updated MRI of her cervical spine to
determine if surgery was indicated. Id. He stated
possible treatment options for the lumbar spine including
ESIs, rhizotomy, and spinal cord stimulator, but indicated
the MRI results did not suggest surgery would be beneficial.
Id. He did not feel that Plaintiff had reached
maximum medical improvement and did not believe she should
return to work at that time. Id.
D. Wooten, Jr., M.D. (“Dr. Wooten”), administered
a lumbar ESI on May 7, 2012. Tr. at 497.
15, 2012, a computed tomography (“CT”) scan of
Plaintiff's cervical spine showed no acute fracture,
dislocation, or significant degenerative changes. Tr. at 431.
reported increased pain in her neck, right shoulder, and
right forearm on May 25, 2012. Tr. at 460. Dr. Aymond
observed Plaintiff to have normal sensation to light touch
and pinprick in the C5-6 and C7 dermatomes and tenderness to
palpation of the posterior aspect of the neck. Id.
He noted Plaintiff's complaints of radicular pain into
the right upper extremity. Id. He assessed cervical
radiculopathy, low back pain, and morbid obesity.
Id. He referred Plaintiff for a new MRI of the
cervical spine and authorized her to remain out of work until
after he had an opportunity to review her MRI results. Tr. at
463 and 463. Plaintiff subsequently received a second lumbar
ESI. Tr. at 494.
underwent an MRI scan of her cervical spine on June 14, 2012,
that showed no disc herniation or significant central
stenosis. Tr. at 415. However, it indicated an annular bulge
at ¶ 5-6 that combined with reversal of the normal
curvature to cause ventral canal narrowing and minimal
ventral cord flattening. Id. It also showed
uncovertebral hypertrophy with mild bilateral foraminal
presented to Beth Price, M.D. (“Dr. Price”), for
a complete physical examination on June 18, 2012. Tr. at 420.
Dr. Price noted sinus tachycardia. Tr. at 422. She observed
Plaintiff to be 63 inches tall and to weigh 260 pounds. Tr.
at 421. Plaintiff requested Phentermine for weight loss, but
Dr. Price declined to prescribe the medication in light of
Plaintiff's abnormal electrocardiogram
(“EKG”). Tr. at 420 and 422. She advised
Plaintiff to eliminate diet sodas and to find a pool for
exercise. Tr. at 422.
followed up with Dr. Aymond to review the results of the
cervical MRI scan on June 19, 2012. Tr. at 464. Dr. Aymond
stated the MRI showed a central disc bulge at the C5-6 level.
Id. Plaintiff continued to report aching pain in her
low back, neck, interscapular area, and bilateral shoulders.
Id. Dr. Aymond observed Plaintiff to have limited
cervical rotation and slightly diminished sensation in the
right C6 dermatome distribution. Id. He recommended
anterior cervical discectomy and fusion at the C5-6 level and
referred Plaintiff to Edward Nolan, M.D. (“Dr.
Nolan”), for management of her low back pain.
Id. He indicated Plaintiff should remain out of work
until after a six-week follow up visit. Tr. at 468.
presented to Dr. Nolan with complaints of pain in her neck,
low back, left hip, and tailbone on July 17, 2012. Tr. at
672. She indicated her pain was aggravated by sitting,
walking, and driving. Id. She stated her pain
affected her sleep and physical and social activities.
Id. Dr. Nolan observed Plaintiff to have intact and
symmetrical cranial reflexes, slightly reduced deep tendon
reflexes, decreased sensation to light touch in her right
upper extremity and left lower extremity, normal
coordination, grossly intact muscle strength, normal tone,
antalgic gait, and negative SLR test. Tr. at 673. Plaintiff
reported moderate pain from her bilateral cervical
paraspinous muscles into the bilateral trapezius muscles;
moderate cervical radicular pain with ROM in the right C5,
C6, and C7 nerve distribution to the hand; moderate pain in
her bilateral lumbar paraspinous muscles; and tenderness to
palpation overlying the L3-4, L4-5, and L5-S1 facet joints.
Id. Dr. Nolan assessed lumbar facet arthropathy and
cervical radiculopathy. Id. He indicated he would
take over management of Plaintiff's medications and would
administer a lumbar facet injection after receiving
authorization from the workers' compensation carrier.
August 7, 2012, Plaintiff reported that she was unable to sit
for more than 30 minutes without experiencing severe pain in
her lower back and coccyx. Tr. at 471. She continued to
complain of pain in her posterior neck and interscapular area
and upper extremity dysesthesias. Id. Dr. Aymond
observed Plaintiff to have limited mobility of the cervical
spine, normal motor strength, and slightly diminished
sensation in the C6 dermatome distribution. Id. He
indicated Plaintiff would proceed with cervical fusion and
authorized her to remain out of work based on her inability
to sit for greater than 30 minutes at a time. Id.
However, on August 15, 2012, he authorized Plaintiff to
return to work with the ability to change positions every two
to four hours as needed. Tr. at 475.
Nolan administered facet lumbar injections to Plaintiff's
bilateral L3-4, L4-5, and L5-S1 areas on August 22, 2012. Tr.
complained of pain in her neck and low back on September 6,
2012. Tr. at 666. She reported greater than 80 percent
initial pain relief from lumbar facet injections, but
indicated the pain had slowly returned to her right lower
back. Id. Dr. Nolan noted moderate pain in
Plaintiff's bilateral cervical paraspinous muscles to the
shoulder, moderate pain in the right lumbar paraspinous
muscles, and moderate pain in the coccyx. Tr. at 666-67. He
indicated he would treat Plaintiff's lumbar facet
arthropathy and coccydynia with injections during her next
visit. Tr. at 667.
Nolan administered facet lumbar injections at the bilateral
L3-4, L4-5, and L5-S1 levels on September 25, 2012. Tr. at
October 10, 2012, Plaintiff reported that she had received
greater than 60 percent initial pain relief from the lumbar
facet injections, but indicated the pain had returned. Tr. at
660. Dr. Nolan noted mild-to-moderate pain to palpation in
the bilateral lumbar paraspinous muscles and moderate pain to
palpation in the left piriformis muscle over the sciatic
nerve. Tr. at 661. He indicated he would administer
transforaminal ESIs during Plaintiff's next visit.
presented to Curtis Worthington, M.D. (“Dr.
Worthington”), for an IME on October 23, 2012. Tr. at
598. Dr. Worthington observed Plaintiff to have normal
station and gait; to be able to walk on her heels and toes
without difficulty; to be tender to palpation along the lower
lumbar spinous process, sacrum, and cervical spine; to
demonstrate full ROM; to have normal tone, bulk, and strength
in all muscle groups; to have no sensory deficits; and to
demonstrate symmetrical reflexes. Id. He reviewed
Plaintiff's imaging studies and interpreted them to show
mild multi-level degenerative changes to the lumbar spine and
degeneration with disc collapse, increased angulation, and
some bulging at the C5-6 level. Tr. at 599. He indicated
Plaintiff had no compression of the spinal cord or clear
compression of the nerve roots. Id. He opined that
Plaintiff had a multifactorial pain syndrome that was
affected by fibromyalgia and obesity. Id. He
recommended a bone scan to rule out a lesion to the lumbar
spine and a cervical discogram to determine if C5-6
discectomy and fusion would be beneficial. Id.
Nolan administered lumbar transforaminal ESIs to
Plaintiff's bilateral L4 and L5 nerve roots on October
24, 2012. Tr. at 658.
complained of low back pain on December 19, 2012. Tr. at 654.
She indicated that her last injection had provided greater
than 80 percent initial pain relief, but that the pain had
returned. Id. She reported that sitting and looking
up and down exacerbated her pain. Id. Dr. Nolan
refilled Plaintiff's medications and indicated he would
administer additional injections during her next visit. Tr.
January 11, 2013, CT discography of Plaintiff's cervical
spine revealed anterior and posterior endplate overgrowth
that extended throughout the annulus in a manner consistent
with degenerative disc disease. Tr. at 485. It further showed
mild canal narrowing secondary to disc osteophyte complex and
likely minimal left and right foraminal encroachment.
Id. Plaintiff underwent a whole body scan on January
16, 2013, that revealed no abnormality in the spine. Tr. at
January 22, 2013, Dr. Worthington explained to Plaintiff that
her pain was multifactorial as a result of neck and low back
pain and fibromyalgia, as opposed to being related entirely
to the lesion at ¶ 5-6. Tr. at 584. However, he
indicated that neck surgery would likely reduce
Plaintiff's neck pain and arm discomfort. Id. He
recommended C5-6 anterior discectomy with decompression of
the spinal cord and nerve roots. Tr. at 585.
Nolan administered injections to Plaintiff's coccyx and
lumbar spine on January 23, 2013. Tr. at 651-52.
returned to Dr. Worthington to review the operative plans on
February 27, 2013. Tr. at 579. Dr. Worthington explained that
he was “less confident in the success of the
operation” because Plaintiff lacked radiculopathic and
myelopathic signs and symptoms. Id. He indicated
that Plaintiff would be admitted for anterior cervical
discectomy at ¶ 5-6. Tr. at 580.
March 7, 2013, Dr. Worthington and Michael C. Noone, M.D.
(“Dr. Noone”), performed anterior cervical
discectomy and fusion with instrumentation at the C5-6 level.
Tr. at 499-502. Plaintiff presented for a postoperative visit
on March 27, 2013, and reported that her headaches and the
numbness and pain in her arms had resolved. Tr. at 577. She
indicated she was better able to use her upper extremities
for a longer period of time, but continued to be hoarse,
cough, choke, and feel short of breath. Id. Dr.
Worthington noted that Plaintiff continued to experience
“a little bit of decreased range of motion, some mild
focal cord problem, and difficulty sleeping, ” but was
doing very well overall. Id. Plaintiff's wound
was clean, dry, and well-healed and she demonstrated no
neurological deficits. Id. Dr. Worthington
prescribed Ativan for sleep and indicated Plaintiff should
begin physical therapy in three weeks. Id.
April 9, 2013, Plaintiff reported that she had received a
30-day supply of Oxycodone, Flexeril, and Lorazepam following
her surgery, but had not finished all of the pills. Tr. at
647. She indicated the injections she received in January had
helped her coccygeal pain, but had not worked as well for her
low back pain. Id. Dr. Nolan noted no abnormalities
on physical examination. Tr. at 647 and 649. He indicated he
would administer injections to Plaintiff's low back and
coccyx during her next visit. Id.
reported pain in her low back and tailbone on May 1, 2013.
Tr. at 645. Dr. Nolan administered lumbar facet and coccyx
injections. Tr. at 645-46.
presented for a physical therapy evaluation on May 6, 2013.
Tr. at 531. She reported a significant decrease in cervical
symptoms following her surgery, but indicated she continued
to be awakened by neck stiffness a couple of times per night
when she took less than a whole Ativan tablet. Id.
She reported she took Lortab an average of once a week when
she felt like she had overexerted herself. Id. She
described her pain as ranging from a four to a six on a
10-point scale and indicated it was exacerbated by rotating
her neck to the right, repetitively turning her head, and
riding in a car. Id. She reported that her headaches
had stopped and she was able to read again. Id.
Physical therapist Julie Black indicated Plaintiff
demonstrated good rehab potential. Tr. at 532. She scheduled
Plaintiff for two-to-three sessions per week for four weeks.
followed up with Dr. Worthington on May 29, 2013, and
reported that her neck was “as good as it can
be.” Tr. at 575. She continued to complain of severe
pain in her tailbone. Id. Dr. Worthington observed
that Plaintiff's surgical wound was well-healed.
Id. He referred Plaintiff for a new MRI of her
lumbar spine. Id.
reported minimal relief from injection therapy on July 11,
2013. Tr. at 644. She complained of moderate coccygeal pain
that intensified with sitting and moderate bilateral lumbar
paraspinous muscle pain. Tr. at 643. Dr. Nolan continued
Plaintiff's medications pending results of an MRI. Tr. at
15, 2013, an MRI scan of Plaintiff's lumbar spine showed
an L5-S1 disc bulge with annular tear that caused moderate
right and ...