United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. HODGES, UNITED STATES MAGISTRATE JUDGE
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 reversed
and remanded for further proceedings as set forth herein.
August 19, 2013, Plaintiff protectively filed applications
for DIB and SSI in which she alleged her disability began on
July 24, 2013. Tr. at 138 and 211-15. Her applications were
denied initially and upon reconsideration. Tr. at 140-43,
145-46, and 192-99. On November 19, 2015, Plaintiff had a
hearing before Administrative Law Judge (“ALJ”)
James R. McHenry, III. Tr. at 63-111 (Hr'g Tr.). The ALJ
issued an unfavorable decision on February 2, 2016, finding
that Plaintiff was not disabled within the meaning of the
Act. Tr. at 32-62. 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 1-7. Thereafter, Plaintiff brought
this action seeking judicial review of the Commissioner's
decision in a complaint filed on July 11, 2017. [ECF No. 1].
Plaintiff's Background and Medical History
was 51 years old at the time of the hearing. Tr. at 83. She
completed high school. Tr. at 86. Her past relevant work
(“PRW”) was as a packer and an inspector. Tr. at
100. She alleges she has been unable to work since July 24,
2013. Tr. at 71.
presented to Thomas A. Leong, M.D. (“Dr. Leong”),
for left knee pain on February 25, 2013. Tr. at 380. She
indicated that she had injured her knee one year prior when
she stepped in a pothole. Id. She denied frank
catching or locking, but endorsed sharp, intermittent medial
and lateral pain. Id. Dr. Leong noted that Plaintiff
had previously undergone right knee arthroscopy. Id.
He observed Plaintiff to have range of motion
(“ROM”) from zero to 125 degrees; to be stable to
varus/valgus stress, Lachman's and posterior drawer
testing; to have posteromedial joint line tenderness; to
endorse pain with full knee flexion; to demonstrate bilateral
grade I pitting edema; to have a good pulse; and to show
normal sensation in the foot. Tr. at 382. He referred
Plaintiff for magnetic resonance imaging (“MRI”)
of the left knee to evaluate a potential meniscal tear.
March 7, 2013, Dr. Leong indicated that Plaintiff's MRI
showed a radial tear of the left lateral meniscus. Tr. at
377. He recommended surgery. Tr. at 379. He performed left
knee arthroscopic debridement of the lateral meniscal tear
and removal of a loose body on March 19, 2013. Tr. at 552-53.
a post-operative evaluation on March 26, 2013, Dr. Leong
indicated Plaintiff was doing well. Tr. at 374. He removed
her sutures, prescribed Lortab, and recommended physical
therapy. Tr. at 375.
April 30, 2013, Plaintiff reported aching in her left knee
that was associated with weather changes, but Dr. Leong
indicated her left knee had improved. Tr. at 383. Plaintiff
complained of a catching and locking sensation in her right
knee and stated her symptoms were worsened by deep flexion
and improved by rest, heat, and ice. Id. Dr. Leong
observed diffuse posteromedial and posterolateral joint line
tenderness in Plaintiff's right knee, but indicated she
had ROM from zero to 125 degrees, no pretibial edema, and
intact sensation of the foot. Tr. at 384. Plaintiff endorsed
mild pain with patellofemoral compression. Id. Dr.
Leong indicated right knee x-rays showed preserved medial,
lateral, and patellofemoral articular intervals. Id.
He administered an injection to Plaintiff's right knee.
Tr. at 385.
17, 2013, Plaintiff presented to her primary care physician
Richard Ruffing, M.D. (“Dr. Ruffing”), for
fatigue and hand pain. Tr. at 406. Dr. Ruffing observed
Plaintiff to be tender in her wrist, but to have adequate
strength. Id. He assessed tendonitis of the wrist
and recommended that Plaintiff apply ice and limit her
activity. Id. He refilled prescriptions for vitamin
D and Zestoretic and prescribed Lortab and Ultram.
25, 2013, Plaintiff presented to the emergency room
(“ER”) at Gaffney Medical Center for pain,
numbness, and tingling in her right hand. Tr. at 391 and 394.
She described her pain as being exacerbated by movement and
noted that it was causing difficulty in performing work tasks
and household chores. Id. The attending physician
diagnosed osteoarthritis and acute tendonitis, administered a
Toradol injection, placed Plaintiff in a wrist splint, and
prescribed Lortab and Indocin. Tr. at 392.
15, 2013, Plaintiff complained of headaches, swelling in her
ankles, and pain, stiffness, and swelling in her wrists. Tr.
at 405. Dr. Ruffing observed tenderness and mildly decreased
ROM in Plaintiff's wrists, but indicated she had adequate
strength. Id. He assessed tendonitis and possible
carpal tunnel syndrome (“CTS”). Id. He
administered an injection to Plaintiff's right wrist and
referred her to a neurologist. Id. He authorized
Plaintiff to remain out of work for a week. Id.
underwent electromyography (“EMG”) and nerve
conduction studies (“NCS”) on July 17, 2013, that
showed mild CTS on the left and moderate-to-severe right
ulnar nerve entrapment at the elbow. Tr. at 416.
25, 2013, Plaintiff presented to orthopedist Walter Grady,
D.O. (“Dr. Grady”), for right wrist and hand
pain. Tr. at 410. She indicated that her employer had
reprimanded her because she had been unable to efficiently
operate an air gun with her hand. Id. She reported
being unable to bend her thumb and index finger effectively.
Id. She rated her pain as an eight on a 10-point
scale. Tr. at 413. Dr. Grady observed swelling and tenderness
over the first dorsal compartment of Plaintiff's right
wrist. Tr. at 410. He noted tenderness to palpation over the
first carpometacarpal (“CMC”) joint articulation
and A1 pulley region of the right thumb. Id. He
indicated Plaintiff had reduced grip strength and ROM, but
normal circulation. Tr. at 410-11. He stated testing revealed
positive Finkelstein's test and grind test in the right
thumb and negative passive elbow flexion test. Tr. at 411. He
found significant flexor digitorum profundus
(“FDP”) tendon and significant abductor intrinsic
weakness that suggested severe ulnar nerve compression.
Id. Dr. Grady stated Plaintiff's EMG/NCS results
showed mild left CTS and moderate-to-severe right cubital
tunnel syndrome. Tr. at 413. He noted that x-rays of
Plaintiff's right thumb indicated joint space narrowing,
radio dense sclerotic changes consistent with advanced
arthritis, and evidence of osteophytic change or bone spurs
at the first CMC joint articulation. Id. He
indicated x-rays of Plaintiff's right wrist showed
evidence of spurring at the distal radioulnar joint
articulation or osteophytic change consistent with
degenerative joint disease and slight volar flexion posturing
of the lunate. Tr. at 413-14. He diagnosed cubital tunnel
syndrome, de Quervain's tenosynovitis, and right thumb
CMC joint arthritis. Tr at 414. He administered injections,
placed Plaintiff in a splint, ordered physical therapy, and
authorized her to remain out of work until August 12, 2013.
Tr. at 415 and 608.
engaged in physical therapy at Regional Rehabilitation
Services from August 5 to August 12, 2013. Tr. at 462-63 and
August 12, 2013, Plaintiff endorsed triggering and locking of
her right thumb. Tr. at 420. Dr. Grady noted evidence of
calcific density in the first and second dorsal compartments
of Plaintiff's right wrist and tenderness over the A1
pulley region, the first dorsal compartment, and the CMC
joint articulation of her right thumb. Id. He
observed positive Finkelstein's test and positive grind
test of the right thumb. Tr. at 421. He scheduled Plaintiff
for ligamentous reconstruction and interposition arthroplasty
of the left first CMC joint. Tr. at 422. On August 14, 2013,
Dr. Grady provided an authorization for Plaintiff to remain
out of work, but indicated he expected she would able to
return to work without restriction on November 18, 2013. Tr.
August 23, 2013, Plaintiff underwent surgical procedures that
included (1) flexor carpi radialis (“FCR”) split
tendon transfer to the base of her right first metacarpal;
(2) palmar oblique ligament reconstruction using the radial
half of the FCR tendon and capsulorrhaphy; (3) FCR
interposition arthroplasty of the right first CMC joint; (4)
carpectomy of one bone trapezium of the right first CMC
joint; (5) excision of a dorsal ganglion cyst area of the
second dorsal compartment of the right wrist; (6) release of
the first dorsal compartment and separate compartment over
the abductor pollicis longus tendon of the right wrist; and
(7) release of the A1 pulley of the right thumb. Tr. at 398.
Dr. Grady noted that the surgery required an additional hour
beyond the amount of time initially contemplated because of
the complexity of the case. Id.
returned to Regional Rehabilitation Services on August 28,
2013, and participated in physical therapy until October 7,
2013. Tr. at 464- 66, 474-97, and 513-16.
September 5, 2013, Dr. Grady indicated Plaintiff was doing
well. Tr. at 455. Plaintiff rated her right wrist pain as a
five. Tr. at 456. She complained of sleep disturbance, and
Dr. Grady prescribed Ambien. Tr. at 457. Dr. Grady instructed
Plaintiff to continue to participate in physical therapy.
September 26, 2013, Dr. Grady noted that he had prescribed an
antibiotic medication earlier in the week to treat a possible
reactive area and a little exudation in Plaintiff's first
CMC joint incision. Tr. at 504. He noted mild tenderness over
the surgical site and very heavy scar tissue and keloid
formation. Tr. at 504 and 506. He prescribed Lortab and
Bactrim. Tr. at 506.
October 3, 2013, Dr. Ruffing completed a mental status
questionnaire. Tr. at 498. He indicated Plaintiff experienced
stress and anxiety. Id. He stated medication had
helped Plaintiff's condition and denied recommending
psychiatric treatment. Id. He described Plaintiff as
being appropriately oriented; having an intact thought
process and appropriate thought content; demonstrating a
worried and anxious mood and affect; and having adequate
attention, concentration, and memory. Id. He rated
Plaintiff's work-related limitation in function due to
her mental impairment as “slight” and indicated
she was capable of managing her funds. Id.
October 7, 2013, Dr. Grady reviewed Plaintiff's physical
therapy notes and indicated the physical therapist's
observations mirrored his own. Tr. at 517. He noted that
Plaintiff's grip strength was 25 pounds on the right and
55 pounds on the left. Id. He stated Plaintiff's
right wrist flexion was 60 degrees and her right wrist
extension was 55 degrees. Id. He indicated Plaintiff
demonstrated good thumb/index pinch. Id. Plaintiff
complained of numbness in the radial sensory distribution of
the middle and ring fingers, and Dr. Grady recommended
aggressive massage. Tr. at 519. He instructed Plaintiff to
continue to participate in physical therapy twice a week for
three weeks. Id.
followed up with Dr. Ruffing for evaluation of hypertension
and gastroesophageal reflux disease (“GERD”) on
October 11, 2013. Tr. at 543-45. Dr. Ruffing observed
Plaintiff to have good strength in her upper and lower
extremities and normal gait. Tr. at 543.
October 28, 2013, Plaintiff complained of numbness in her
fingers and indicated that Dr. Ruffing had attributed the
symptom to CTS. Tr. at 522. Dr. Grady observed Plaintiff to
have well-healed surgical scars and keloid scar formation
over the first CMC joint articulation of her right thumb.
Id. He observed Plaintiff to have right wrist
flexion to 50 degrees and extension to 60 degrees.
Id. He noted that Plaintiff had reduced grip
strength and reduced thumb/index pinch at 2-2. Tr. at
522-23. He stated Plaintiff had positive Phalen's and
carpal compression tests and negative Tinel's test over
the carpal tunnel of the right wrist. Tr. at 522. He assessed
right thumb trigger finger and right CTS and ordered EMG/NCS
and additional physical therapy. Tr. at 524.
agency psychological consultant Timothy Laskis, Ph.D.
(“Dr. Laskis”), completed a psychiatric review
technique on November 12, 2013. Tr. at 118-19. He considered
Listing 12.06 for anxiety-related disorders, but concluded
that Plaintiff's mental impairment was non-severe because
it resulted in no repeated episodes of decompensation, no
restriction of activities of daily living
(“ADLs”), mild difficulties in maintaining social
functioning, and mild difficulties in maintaining
concentration, persistence, or pace. Id.
November 12, 2013, Plaintiff reported numbness in her right
fingertips and posterior hand at the metacarpophalangeal
(“MCP”) joint. Tr. at 649. She endorsed loss of
grip in her right hand. Id. EMG/NCS showed moderate
right ulnar nerve entrapment at the elbow and chronic axonal
changes in the right median motor nerve. Tr. at 648.
agency medical consultant Joseph Geer, M.D. (“Dr.
Geer”), completed a physical residual functional
capacity (“RFC”) assessment on November 14, 2013.
Tr. at 119-22. He assessed the following limitations:
occasionally lifting and/or carrying 20 pounds; frequently
lifting and/or carrying 10 pounds; standing and/or walking
for a total of about six hours in an eight-hour workday;
sitting for a total of about six hours in an eight-hour
workday; frequently pushing and pulling with the bilateral
upper extremities; frequently crouching, kneeling, and
climbing ramps and stairs; occasionally crawling and climbing
ladders, ropes, or scaffolds; frequently handling with the
right upper extremity; avoiding concentrated exposure to
humidity and extreme heat and cold; and avoiding even
moderate exposure to hazards. Id.
November 20, 2013, Plaintiff complained of increased
tenderness and pain in her right thumb. Tr. at 526. She
indicated she had noticed an audible popping sound from her
knee while walking through her home that had produced pain.
Tr. at 529. Dr. Grady observed Plaintiff to have keloid scar
formation, scarring down the radial sensory nerve branches,
and tenderness over the first compartment and MCP joint.
Id. He recommended that Plaintiff engage in scar
massage and desensitization. Id. He prescribed
Lidoderm patches and Naproxen and indicated he would address
Plaintiff's ability to return to work during her next
visit. Tr. at 528 and 529.
December 18, 2013, Plaintiff complained of mild tenderness
over the first CMC joint articulation and numbness and
tingling in the fingers of her right hand. Tr. at 530. Dr.
Grady observed no abnormality in Plaintiff's median motor
nerve, but noted positive Phalen's test on the right
after 15 seconds. Id. He diagnosed osteoarthritis of
the CMC joint of the right thumb and right CTS and prescribed
a Medrol Dosepak. Tr. at 532. He stated Plaintiff also had
signs of cubital tunnel syndrome of the right elbow. Tr. at
533. He indicated he would consider injections into the
cubital and carpal tunnels if the oral corticosteroid was
ineffective. Id. He stated Plaintiff would be a
candidate for cubital tunnel release and carpal tunnel
release if oral corticosteroids and injections were
January 16, 2014, Dr. Grady noted that Plaintiff's work
had required extensive use of her hands. Tr. at 534.
Plaintiff stated her right hand pain was constantly present.
Id. She rated it as a three. Id. Dr. Grady
noted that Plaintiff was emotional because she felt that the
pain and weakness in her hand would prevent her from
performing her job duties to meet her employer's
expectations. Id. He noted 3 right thumb/index
pinch strength. Tr. at 535. He released Plaintiff to
“engage in modified work duty on a permanent basis
relative to her right dominant hand” with a lifting
restriction of 10 pounds and noted that she would need to
wear a splint while working. Tr. at 536 and 664. He further
stated that Plaintiff should engage in no torqueing or
twisting activities with her right hand. Id. He
instructed Plaintiff to continue her home exercise program
and to return to him for treatment as needed. Id.
January 24, 2014, Plaintiff complained of facial and neck
swelling and right knee pain. Tr. at 689. Dr. Ruffing noted
that Plaintiff desired to return to work, but was not certain
if she would be able to perform her job duties. Id.
He recommended that Plaintiff return to work, but follow up
if she could not continue to work. Id. He ordered
x-rays of Plaintiff's right knee that showed medial
compartment degenerative joint disease. Tr. at 745.
February 21, 2014, Plaintiff complained of edema in her feet
and hands and pain and stiffness in her back, knees, hands,
and arms. Tr. at 685. She indicated she had been terminated
from her job because of problems using her hands.
Id. Dr. Ruffing observed no abnormalities on
physical examination. Id. He assessed arthralgia,
GERD, and uncontrolled, type II diabetes. Tr. at 683. He
administered a Depo-Medrol injection and refilled
Plaintiff's medications. Tr. at 685-86.
February 26, 2014, a second state agency psychological
consultant, Larry Clanton, Ph.D. (“Dr. Clanton”),
found Plaintiff's mental impairments to be non-severe.
Tr. at 131-32.
second state agency medical consultant, William Hopkins, M.D.
(“Dr. Hopkins”), assessed the same physical RFC
as Dr. Geer, on February 28, 2014. Compare Tr. at
119-22, with Tr. at 133-35.
April 9, 2014, Plaintiff complained of pain in her right arm
and swelling in her right arm and bilateral feet. Tr. at
680-81. Dr. Ruffing observed Plaintiff to have full ROM and
good strength in her extremities, but noted tenderness and
mild swelling in the middle of her left foot. Tr. at ...