Sanders-Hall v. Berryhill

          REPORT AND RECOMMENDATION

          Shiva V. Hodges United States 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”). 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.

         I. Relevant Background

         A. Procedural History

         On August 14, 2012, Plaintiff protectively filed an application for DIB in which she alleged her disability began on March 22, 2012. Tr. at 87 and 174-81. Her application was denied initially and upon reconsideration. Tr. at 105-09, 111-16. On June 14, 2016, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Paul Elkin. Tr. at 31-74 (Hr'g Tr.). The ALJ issued an unfavorable decision on July 14, 2016, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 8-30. 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 August 7, 2017. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 48 years old on her date last insured. Tr. at 23. She completed the ninth grade. Tr. at 42. Her past relevant work (“PRW”) was as a cashier and a fiber machine operator. Tr. at 66. She alleges she has been unable to work since March 22, 2012. Tr. at 174.

         2. Medical History

         Plaintiff underwent anterior cervical fusion at the C4-5 level in April 2002. Tr. at 337 and 358.

         On October 11, 2012, neurosurgeon J. Marc Guitton, M.D. (“Dr. Guitton”), informed Plaintiff that magnetic resonance imaging (“MRI”) of her lumbar spine showed degenerative changes with mild-to-moderate stenosis at ¶ 4-5. Tr. at 300. He assessed lumbar spondylosis, lumbar disc disease, lumbar radiculopathy, and lumbar stenosis. Id. He advised Plaintiff that treatment options included medications, injections, therapy, and surgery. Id.

         On December 12, 2011, Plaintiff presented to pain management specialist Allen L. Sloan, M.D. (“Dr. Sloan”). Tr. at 328. She reported sharp, aching pain across her lower back that was exacerbated by maintaining positions, standing, walking, sitting, and climbing stairs. Id. Dr. Sloan observed Plaintiff to have difficulty rising from a seated to a standing position; a stiff and slightly forward-flexed gait; decreased range of motion (“ROM”) to extension; tenderness to palpation in the midline and paraspinal facets at ¶ 3-4, L4-5, and L5-S1 and over the bilateral sacroiliac joints; positive Patrick's sign; and pain on straight-leg raise (“SLR”) testing. Id. He administered bilateral L3-4, L4-5, and L5-S1 lumbar facet and sacroiliac joint injections. Tr. at 328-29.

         On February 20, 2012, Plaintiff reported that her pain had worsened. Tr. at 303. Dr. Guitton observed Plaintiff to have limited motion in her back; lumbar stiffness; positive bilateral SLR testing; and intact strength and sensation. Id. Plaintiff indicated she would consider surgery. Id.

         On March 13, 2012, an MRI of Plaintiff's lumbar spine showed moderate central canal stenosis at ¶ 4-5. Tr. at 314-15.

         On March 23, 2012, Dr. Guitton performed decompressive lumbar laminectomy at Plaintiff's L4-5 level. Tr. at 291. Plaintiff reported she was doing well during a postoperative visit on April 23, 2012. Tr. at 305. Dr. Guitton advised Plaintiff to gradually increase her activity and to be careful with bending and lifting. Id.

         Plaintiff presented to Kraig Wangsnes, M.D. (“Dr. Wangsnes”), for sleep apnea follow up on May 1, 2012. Tr. at 395. She complained of an irregular heartbeat and pain in her back and leg. Tr. at 396. Her blood pressure was elevated at 160/90 mm/Hg. Tr. at 397. Dr. Wangsnes encouraged Plaintiff to use her continuous positive airway pressure (“CPAP”) machine, to increase her dose of Micardis/Hydrochlorothiazide, and to maintain a log of her blood pressure and pulse readings. Tr. at 396 and 398.

         On June 12, 2012, Plaintiff presented to Julie Sears, P.A. (“Ms. Sears”), to follow up on sleep apnea and hypertension. Tr. at 398. She reported she was tolerating her blood pressure medications. Tr. at 399. Ms. Sears reviewed Plaintiff's log and noted that her blood pressure readings were controlled. Id. Her diagnostic impressions were dizziness, controlled hypertension, migraine, palpitations, and degenerative disc disease. Tr. at 400.

         On July 16, 2012, Plaintiff complained to Dr. Guitton's nurse of pain in her right knee, left foot, and lower back and swelling in her bilateral ankles and feet. Tr. at 306.

         On July 17, 2012, Plaintiff complained of pain in her lower back and left foot. Tr. at 337. Podiatrist Mackie J. Walker, D.P.M. (“Dr. Walker”), observed Plaintiff's left heel temperature to be increased with significant effusion and swelling. Id. He stated he was unable to palpate Plaintiff's pulse on the left side of her foot because of 2 bilateral pitting edema. Id. He observed decreased sensorium bilaterally on monofilament testing and abnormal sharp/dull and light touch sensation. Id. He noted 4/5 muscle strength, limited dorsiflexion, and exquisite pain on the left Achilles tendon. Id. He described a palpable washboard-type feel to Plaintiff's bilateral plantar fascia that he considered to be consistent with plantar fibromatosis. Id. Dr. Walker indicated ultrasound images showed multiple interligamentous legions. Id. He stated examination of Plaintiff's Achilles tendon revealed a very hypoechoic signal and apparent disruption and tear on the medial aspect. Id. He placed Plaintiff in a controlled ankle movement (“CAM”) walker and referred her for an MRI of her left ankle and midfoot. Tr. at 338.

         On July 19, 2012, an MRI of Plaintiff's left ankle showed severe distal Achilles tendinopathy, tendinitis, and interstitial partial tearing, as well as mild thickening of the proximal plantar fascia. Tr. at 339. There was no evidence of plantar fibromatosis. Id. An MRI of Plaintiff's right ankle indicated an unremarkable Achilles tendon; very minimal signal abnormality at the plantar fascial insertion; mild hyperintensity surrounding the lateral fascicle; soft tissue edema over the anterolateral ankle and foot; unremarkable medial and lateral flexor and extensor tendons; fluid within the sinus tarsi projecting from the posterior subtalar joint; and intact talofibular, calcaneofibular, and deltoid ligaments. Tr. at 340. It showed no clear evidence of plantar fibromatosis. Id.

         On July 31, 2012, Plaintiff complained of pain in her back, foot, left suprascapular area, and bilateral knees. Tr. at 326. Dr. Sloan observed Plaintiff to have positive patellar grinding of the bilateral knees and to be tender in her left suprascapular area, the left paraspinous muscles of her cervical spine, and the medial joint lines of her bilateral knees. Tr. at 327. He assessed “lumbar spondylosis, facet arthropathy, and sacroiliac/hip pain improved with recent lumbar laminectomy, ” cervical spondylosis and suprascapular neuropathy, and bilateral knee patellofemoral arthritis. Id. He refilled Plaintiff's prescriptions for Flexeril and Lortab and indicated she should follow up in three months for injections. Id.

         On August 28, 2012, Dr. Walker informed Plaintiff that the MRI demonstrated interstitial tearing of the left side of the Achilles tendon, tendinitis on the right, and arthritis at the ankle. Tr. at 341. He noted that Plaintiff had significant peripheral neuropathy. Id. He instructed Plaintiff to continue to take Theramine and Naproxen. Id.

         On October 9, 2012, Plaintiff reported pain and swelling in her left Achilles area and pain in her knee. Tr. at 371. X-rays of Plaintiff's heel showed modest posterior heel spur formation. Id. Dr. Walker indicated Plaintiff appeared to “have a little periostitis posteriorly and inferiorly, ” but intact osteology. Id. He stated Plaintiff had “a mild Haglund's deformity, but nothing severe.” Id. He prescribed an anti-inflammatory compound of nonsteroidal anti-inflammatory drugs (“NSAIDs”), Ketamine, Tramadol, Bupivacaine, and Clonidine. Id.

         On October 30, 2012, Plaintiff complained of left foot pain at the contralateral side, plantar fascia, and Achilles tendon. Tr. at 372. Dr. Walker observed that Plaintiff remained “quite effused at the Achilles tendon with Haglund's deformity and significant periostitis.” Id. He placed Plaintiff in a Velocity-type brace to immobilize the back of her left foot. Id.

         On November 13, 2012, Plaintiff complained that the topical medication had provided little relief and that the brace had irritated her leg and tendon. Tr. at 373. Dr. Walker observed that Plaintiff continued to have significant Haglund's deformity and bursitis at the medial insertion. Id. He prescribed a steroid, but indicated he would consider surgery. Id.

         On November 26, 2012, Dr. Walker described surgery that would include removal of a portion of Plaintiff's left heel bone, repair of the left Achilles tendon, and permanent removal of the third, fourth, and fifth toenails on the right foot. Tr. at 374. Plaintiff communicated her understanding and desire to proceed with surgery, and Dr. Walker performed it on December 28, 2012. Tr. at 374 and 376.

         On January 7, 2013, Plaintiff's surgical wounds showed no signs of infection and x-rays of her left heel showed “excellent reduction of deformity.” Tr. at 377-78.

         On January 14, 2013, Plaintiff reported constant chest heaviness and dyspnea on exertion. Tr. at 401. She complained that she felt claustrophobic and was unable to continue to use her CPAP machine. Id. Ms. Sears indicated Plaintiff's pressure readings had been controlled. Id. A physical examination was normal. Tr. at 403.

         On January 7, 2013, Dr. Walker noted that Plaintiff's wounds were healing well, but that she had slight dehiscence proximally. Tr. at 379. He instructed Plaintiff to wean off the walker and to continue to use the ankle-foot orthosis (“AFO”) with limited ambulation. Id.

         On January 29, 2013, Plaintiff reported minimal discomfort in her feet. Tr. at 380. Dr. Walker observed Plaintiff to have slight central dehiscence, but to be healing. Id. He prescribed a topical wound medication and instructed Plaintiff to begin ROM exercises and increase partial weight bearing as tolerated. Id.

         On February 14, 2013, Dr. Walker stated Plaintiff's heel was “remodeling very nicely, ” but he noted Plaintiff had some wound complications and pain. Tr. at 381. He stated Plaintiff had recently been diagnosed with diabetes. Id. He prescribed another topical wound medication and instructed Plaintiff to monitor her wounds for signs of infection. Id.

         On March 11, 2013, Dr. Walker indicated Plaintiff's wound had finally healed and that she was doing “reasonably well.” Tr. at 382. He instructed Plaintiff to follow up in three weeks and indicated he would refer her to physical therapy at that time. Id.

         Plaintiff presented to Susan J. Tankersley, M.D. (“Dr. Tankersley”), for a consultative examination on March 27, 2013. Tr. at 358-62. She complained of joint pain in her neck, lower back, knee, leg, and left foot. Tr. at 358. She described her lower back pain as frequently radiating to her thoracic spine and rarely radiating to her lower extremities. Tr. at 359. She stated her bilateral anteromedial thighs felt numb all the time. Id. She reported persistent muscle spasms and indicated her pain was exacerbated by prolonged sitting, standing, lifting, and bending. Id. She complained of swelling in her bilateral feet that was worse on the left than the right. Id. She indicated she had experienced prolonged healing following Achilles tendon repair surgery. Id.

         Dr. Tankersley observed Plaintiff to be ambulating with a CAM walker and an antalgic and uneven gait. Tr. at 360. Plaintiff's blood pressure was elevated at 150/90 mm/Hg. Id. She was obese at 5' 2” tall and 225 pounds. Id. Dr. Tankersley observed no edema, muscle wasting, or significant degenerative joint changes and intact sensorium, strength, and ROM in Plaintiff's bilateral upper extremities. Tr. at 361. She noted 2 bimalleolar edema in Plaintiff's left lower extremity and 1 pretibial edema in her right lower extremity. Id. She indicated Plaintiff had trace effusion in her bilateral knees that was more pronounced on the right. Id. She observed no muscle wasting. Id. She noted that Plaintiff had “fairly scattered paresthesias to touch throughout both legs.” Id. She indicated Plaintiff had intact strength on the right and 4 to 4-/5 proximal and distal strength on the left. Id. She stated Plaintiff had intact ROM in her hips. Id. She noted crepitus on ROM of Plaintiff's bilateral knees and decreased ROM to flexion and extension of the right knee. Id. She indicated Plaintiff had positive Lachman's and McMurray's tests at the right knee. Id. She observed reduced ROM of Plaintiff's right ankle. Id. She noted that Plaintiff had “essentially no range of motion at all” at the left ankle, but indicated that she did not “push it” as she had not yet been cleared for physical therapy. Id.

         Dr. Tankersley observed Plaintiff to have intact cranial nerves, normal tone, and no rest or indention tremors or bradykinesis. Id. She indicated Plaintiff was unable to toe or heel stand. Id. She was unable to elicit any reflexes. Id. She noted paraspinous muscle spasms in Plaintiff's lumbar and cervical spine and muscle spasms in her trapezius and strap muscles. Id. She indicated Plaintiff's cervical spine was tender in all planes, but that her ROM was normal, aside from right rotation that was reduced to 60 degrees. Id. She stated Plaintiff's lumbar ROM was reduced to 65 degrees on forward flexion, but was otherwise intact. Tr. at 362. The SLR test was negative in the sitting and supine positions. Id. An x-ray of Plaintiff's left knee showed minimal degenerative changes and no acute osseous abnormality. Tr. at 357.

         Dr. Tankersley's impressions were chronic neck pain with history of degenerative joint and disc disease of the cervical spine, status post anterior cervical fusion at ¶ 4-5; chronic lower back pain with history of degenerative joint disease, degenerative disc disease of the lumbar spine, status post discectomy and laminectomy in July 2012; left foot and ankle pain with history of left Achilles tendinopathy and tear, status post repair in December 2012; right knee pain with probable osteoarthritis and possible internal derangement; new-onset diabetes mellitus; history of sleep apnea; history of hypertension; history of migraine-type headaches; new-onset dysphagia with history of gastroesophageal reflux disease (“GERD”); history of depression and anxiety; and obesity. Tr. at 362.

         On June 13, 2013, a colonoscopy showed diverticulitis and multiple colon polyps. Tr. at 713. On August 13, 2013, upper gastrointestinal endoscopy indicated a normal esophagus, stomach, and duodenum. Tr. at 716.

         Plaintiff complained of increased pain in her feet and bilateral legs on September 20, 2013. Tr. at 424. She indicated she was hardly able to wear a shoe or ambulate. Id. Dr. Walker observed that Plaintiff's gait was antalgic. Id. X-rays of Plaintiff's bilateral ankles showed recurring bilateral heel spurs with decreased calcaneal inclination angle. Id. Dr. Walker indicated Plaintiff was experiencing pain related to diabetic neuropathy and had significant scarring and thickening of the tendon. Id. He prescribed Metanx. Id.

         On September 27, 2013, an MRI of Plaintiff's left ankle showed a greater degree of thickening and signal abnormality within the distal Achilles tendon. Tr. at 426.

         Dr. Walker fitted Plaintiff for an orthotic device on October 30, 2013. Tr. at 427. On November 13, 2013, Plaintiff complained of heavy and painful scarring on her anterior ankle and left foot that was irritated by wearing shoes. Tr. at 428. She indicated the orthotic provided relief from plantar fasciitis. Id. Dr. Walker prescribed a scar cream and refilled Metanx. Id.

         On November 27, 2013, x-rays of Plaintiff's bilateral knees showed advanced degenerative joint disease that primarily involved the medial tibial femoral compartments and was worse on the right than the left. Tr. at 458.

         Plaintiff complained of pain on December 11, 2013. Tr. at 429. Dr. Walker described Plaintiff's Achilles tendon as “quite puffy” and indicated she had either developed a cyst at the Achilles insertion or sustained another tear. Id. An MRI of the left ankle did not suggest a new Achilles tendon tear. Tr. at 431.

         On January 16, 2014, Dr. Walker observed Plaintiff to demonstrate an antalgic gait and pain on palpation. Tr. at 432. He instructed Plaintiff to continue home physical therapy and to use the topical compound. Id.

         On February 18, 2014, Plaintiff reported that her Achilles tendon was improving and responding well to the topical compound and that her scar was remodeling well. Tr. at 433. She indicated orthotics were providing some relief and support. Id.

         On March 11, 2014, Dr. Walker noted that Plaintiff's plantar fasciitis continued to improve, but still persisted. Tr. at 434. He indicated the edema had decreased. Id. He instructed Plaintiff to continue to use the topical compound. Id.

         On April 4, 2014, Plaintiff complained of heel and ankle pain with cramping and burning, as well as a fractured right fifth toe. Tr. at 435. Dr. Walker administered an injection of Depo-Medrol and Carbocaine and instructed Plaintiff to continue to take Vimovo. Id.

         Plaintiff complained of left ankle and foot pain on May 16, 2014. Tr. at 436. She reported some relief from the injection, but continued to endorse some pain and burning. Id. Dr. Walker observed Plaintiff to have 1 pedal edema on the right and 2 pedal edema on the left. Tr. at 438. He noted swelling, deformity, and hindfoot varus on the right and swelling and hindfoot varus on the left. Id. He observed tenderness of the calcaneal tuberosity, the Achilles tendon insertion, and the bilateral plantar fascia and Achilles tendons. Id. Plaintiff demonstrated 4/5 strength in the bilateral peroneus longus, brevis, and gastrocnemius. Tr. at 439. She had no plantar or Babinski reflex on the left or right. Id. She had hypersensitivities at the lateral plantar nerve, the medial plantar nerve, and the deep peroneal nerve and tactile dysesthesia/hyperesthesia in her bilateral distal extremities. Id. Dr. Walker assessed Achilles bursitis, calcaneal spur, tenosynovitis of the foot, plantar fascial fibromatosis, neurological disorder associated with type II diabetes mellitus, thoracic neuritis, obesity, and cellulitis and abscess of the upper arm. Id.

         On December 4, 2014, Dr. Walker examined Plaintiff's left heel with ultrasound. Tr. at 443. He noted a thickened and hypoechoic ligament and the plantar facia's insertion into the inferior tuberosity of the left calcaneus. Id. The left plantar fascia was approximately twice its normal thickness. Id. Dr. Walker stated the findings were consistent with acute plantar fasciitis and tarsal tunnel syndrome of the left foot. Id. He administered an injection at the left peroneal area. Id.

         On December 30, 2014, Plaintiff rated her pain as a seven. Tr. at 474. She described sharp, aching pain across her back, both hips, and her right knee that was aggravated by activities of daily living (“ADLs”), walking distances, and maintaining positions for any length of time. Id. Dr. Sloan administered bilateral facet joint injections at ¶ 3-4, L4-5, and L5-S1. Id.

         On January 8, 2015, Dr. Walker observed 1 pedal edema to Plaintiff's bilateral feet. Tr. at 447. He described Plaintiff as having an antalgic gait on the right and ambulating with a cane. Id. He noted Haglund's deformity, hindfoot varus, and midfoot cavus in the bilateral feet. Id. Plaintiff demonstrated tenderness at the Achilles tendon insertion, sinus tarsi, peroneal retinaculum, and deltoid ligament. Id. She reported painful ROM and decreased subtalar ROM bilaterally. Id. She had 4/5 strength at the bilateral gastrocnemius. Tr. at 448. Her reflexes were diminished in her bilateral ankles. Id. She was hypersensitive at her bilateral medial and lateral plantar nerves. Id. She had tactile dysesthesia/hyperesthesia in her bilateral distal extremities. Id. Tinel's test was positive bilaterally. Id.

         Plaintiff presented to Leopoldo Muniz, M.D. (“Dr. Muniz”), for a primary care new patient visit on January 13, 2015. Tr. at 570. Dr. Muniz noted tenderness to Plaintiff's lumbar spine, negative SLR test, and good ROM, sensation, pulses, and strength. Tr. at 571. He instructed Plaintiff to stop smoking and referred her for blood work and urinalysis. Tr. at 572.

         On January 22, 2015, Plaintiff rated her pain as an eight and complained of spasms in her lower back and legs. Tr. at 471. Dr. Sloan observed Plaintiff to have an abnormal gait; bilateral shoulder tenderness to palpation; limited ROM and 4/5 muscle strength of the upper extremities; bilateral knee joint crepitus; bilateral hip tenderness radiating to the buttocks; decreased ROM and 4/5 strength of the bilateral lower extremities; middle and lower back tenderness to palpation; 4/5 strength and decreased ROM of the spine; cervical tenderness with palpation; and decreased reflexes. Tr. at 472.

         On January 28, 2015, Plaintiff reported doing well in general, but complained of tenderness over her left elbow. Tr. at 568. Dr. Muniz indicated Plaintiff's blood sugar had decreased. Id. He noted a small nodule over Plaintiff's left elbow, but indicated she demonstrated good ROM, sensation, pulses, and strength. Tr. at 569. He referred Plaintiff for an ultrasound of her left elbow and recommended that the frequency of her steroid injections be decreased because of adrenal insufficiency. Id.

         On February 12, 2015, Dr. Walker fitted an ankle stabilizer to Plaintiff's right foot. Tr. at 453.

         On February 18, 2015, Dr. Muniz indicated the ultrasound showed a cystic mass that was likely a synovial cyst, but possibly a ganglion cyst or schwannoma. Tr. at 581. He recommended an MRI of the left elbow. Id.

         On February 19, 2015, Plaintiff rated her pain as a ten. Tr. at 467. Dr. Sloan noted abnormal gait; bilateral shoulder tenderness to palpation; 4/5 muscle strength in the bilateral upper extremities; limited upper extremity ROM; bilateral knee joint crepitus; bilateral hip tenderness radiating into the buttocks; decreased ROM in the bilateral lower extremities; 4/5 muscle strength in the bilateral lower extremities; and decreased reflexes. Tr. at 468. He observed no edema and indicated Plaintiff had intact sensation to light touch. Id. He instructed Plaintiff to quit smoking and to continue to take the same medications. Tr. at 469.

         On February 26, 2015, Plaintiff reported some improvement in her right ankle. Tr. at 658. Dr. Walker instructed her to continue the same treatment regimen. Id.

         On March 9, 2015, Plaintiff presented to orthopedist Andrew W. Torrance, M.D. (“Dr. Torrance”), for painful swelling of her left elbow. Tr. at 476. Dr. Torrance assessed a complex, multi-lobulated cystic structure at the anterior lateral aspect of Plaintiff's left elbow that was likely a ganglion cyst. Id. He performed ultrasound-guided aspiration on March 11, 2015. Tr. at 477.

         On March 12, 2015, Dr. Walker observed Plaintiff to be obese and in distress. Tr. at 492. He indicated Plaintiff was ambulating with crutches and an antalgic gait. Id. He noted 1 bilateral pretibial edema. Id. He observed deformities in Plaintiff's bilateral feet, tenderness to palpation, decreased ROM and strength, medial column collapse, hammertoe deformities, neurological dysesthesias and hypersensitivities, and positive Tinel's test. Id.

         On March 19, 2015, Plaintiff complained of pain in her right knee and lower back. Tr. at 462. She rated her back pain as a seven and her knee pain as a ten. Id. Dr. Sloan observed Plaintiff to ambulate with an antalgic, waddling gait with boots on her bilateral feet; to have bilateral knee joint crepitus; to have bilateral hip tenderness radiating into her buttocks; to demonstrate decreased ROM and 4/5 muscle strength in her bilateral lower extremities; to have minimal bilateral ankle swelling; to demonstrate tenderness to palpation in her lower back; and to demonstrate decreased reflexes. Id. He made no adjustments to Plaintiff's medication regimen. Id.

         Plaintiff reported feeling better on March 24, 2015. Tr. at 584. Dr. Muniz continued her on the same medications and instructed her to follow a low-salt diet, avoid ...