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Jeffries v. Berryhill

United States District Court, D. South Carolina

April 13, 2018

Partheane Jeffries, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.



         This appeal from a denial of social security benefits is before the court for a Report and Recommendation (“Report”) pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On 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].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff 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.

         2. Medical History

         Plaintiff 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. Id.

         On 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.

         During 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.

         On 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.

         On May 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. Id.

         On May 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.

         On July 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.

         Plaintiff 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.

         On July 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.

         Plaintiff engaged in physical therapy at Regional Rehabilitation Services from August 5 to August 12, 2013. Tr. at 462-63 and 467-73.

         On 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. at 613.

         On 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.

         Plaintiff 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.

         On 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. Id.

         On 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.

         On 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.

         On 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.

         Plaintiff 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.

         On 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.

         State 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.

         On 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.

         State 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.

         On 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.

         On 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 effective. Id.

         On 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.

         On 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.

         On 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.

         On 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.

         A 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.

         On 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 ...

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