United States District Court, D. South Carolina, Greenville Division
REPORT OF MAGISTRATE JUDGE
F. McDonald United States Magistrate Judge.
case is before the court for a report and recommendation
pursuant to Local Civil Rule 73.02(B)(2)(a)(D.S.C.),
concerning the disposition of Social Security cases in this
District, and Title 28, United States Code, Section
plaintiff brought this action pursuant to Section 205(g) of
the Social Security Act, as amended (42 U.S.C. 405(g)) to
obtain judicial review of a final decision of the
Commissioner of Social Security denying her claim for
disability insurance benefits under Title II of the Social
plaintiff filed an application for disability insurance
benefits (“DIB”) on May 28, 2013, alleging that
she became unable to work on December 4, 2008. The
application was denied initially and on reconsideration by
the Social Security Administration. On June 25, 2014, the
plaintiff requested a hearing. The administrative law judge
(“ALJ”), before whom the plaintiff and William W.
Stewart, an impartial vocational expert, appeared on June 10,
2016, considered the case de novo and, on August 2,
2016, found that the plaintiff was not under a disability as
defined in the Social Security Act, as amended (Tr. 17-26).
The ALJ's finding became the final decision of the
Commissioner of Social Security when the Appeals Council
denied the plaintiff's request for review on May 31, 2017
(Tr. 1-3). The plaintiff then filed this action for judicial
making the determination that the plaintiff is not entitled
to benefits, the Commissioner has adopted the following
findings of the ALJ:
(1) The claimant last met the insured status requirements of
the Social Security Act on March 31, 2014.
(2) The claimant did not engage in substantial gainful
activity during the period from her alleged onset date of
December 4, 2008, through her date last insured of March 31,
2014 (20 C.F.R. § 404.1571 et seq).
(3) Through the date last insured, the claimant had the
following severe impairment: degenerative disc disease (20
C.F.R. § 404.1520(c)).
(4) Through the date last insured, the claimant did not have
an impairment or combination of impairments that met or
medically equaled the severity of one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20
C.F.R. §§ 404.1520(d), 404.1525, 404.1526).
(5) After careful consideration of the entire record, the
undersigned finds that, through the date last insured, the
claimant had the residual functional capacity to perform
sedentary work as defined in 20 C.F.R. § 404.1567(a)
with restrictions of lifting, carrying, pushing, and pulling
ten pounds occasionally and less than ten pounds frequently;
sitting six hours and standing and walking up to two hours in
an eight-hour workday. No. climbing of ladders, ropes, or
scaffolds; occasional climbing of ramps and stairs, kneeling,
crouching, crawling, and stooping; frequent reaching with
bilateral upper extremities in all directions, including
overhead and handling. Furthermore, the claimant should not
perform work-related activities in direct sunlight without
proper eye protection, requiring more than occasional
exposure to extreme temperatures or humidity, or work
involving dangerous machinery or around unprotected heights.
(6) Through the date last insured, the claimant was capable
of performing past relevant work as a claims technician. This
work did not require the performance of work-related
activities precluded by the claimant's residual
functional capacity (20 C.F.R. § 404.1565).
(7) The claimant was not under a disability, as defined in
the Social Security Act, at any time from December 4, 2008,
the alleged onset date, through March 31, 2014, the date last
insured (20 C.F.R. § 404.1520(f)).
only issues before the court are whether proper legal
standards were applied and whether the final decision of the
Commissioner is supported by substantial evidence.
42 U.S.C. § 423(d)(1)(A), (d)(5), as well as pursuant to
the regulations formulated by the Commissioner, the plaintiff
has the burden of proving disability, which is defined as an
“inability to do any substantial gainful activity by
reason of any medically determinable physical or mental
impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period
of not less than 12 months.” 20 C.F.R. §
facilitate a uniform and efficient processing of disability
claims, the Social Security Act has by regulation reduced the
statutory definition of “disability” to a series
of five sequential questions. An examiner must consider
whether the claimant (1) is engaged in substantial gainful
activity, (2) has a severe impairment, (3) has an impairment
that meets or medically equals an impairment contained in the
Listing of Impairments found at 20 C.F.R. Pt. 404, Subpt. P,
App. 1, (4) can perform his past relevant work, and (5) can
perform other work. Id. § 404.1520. If an
individual is found not disabled at any step, further inquiry
is unnecessary. Id. § 404.1520(a)(4).
claimant must make a prima facie case of disability
by showing he is unable to return to his past relevant work
because of his impairments. Grant v. Schweiker, 699
F.2d 189, 191 (4th Cir. 1983). Once an individual
has established a prima facie case of disability,
the burden shifts to the Commissioner to establish that the
plaintiff can perform alternative work and that such work
exists in the national economy. Id. (citing 42
U.S.C. § 423(d)(2)(A)). The Commissioner may carry this
burden by obtaining testimony from a vocational expert.
Id. at 192.
to 42 U.S.C. § 405(g), the court may review the
Commissioner's denial of benefits. However, this review
is limited to considering whether the Commissioner's
findings “are supported by substantial evidence and
were reached through application of the correct legal
standard.” Craig v. Chater, 76 F.3d 585, 589
(4th Cir. 1996). “Substantial evidence” means
“such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion; it consists of
more than a mere scintilla of evidence but may be somewhat
less than a preponderance.” Id. In reviewing
the evidence, the court may not “undertake to re-weigh
conflicting evidence, make credibility determinations, or
substitute [its] judgment for that of the
[Commissioner].” Id. Consequently, even if the
court disagrees with Commissioner's decision, the court
must uphold it if it is supported by substantial evidence.
Blalock v. Richardson, 483 F.2d 773, 775
(4th Cir. 1972).
plaintiff was 54 years old on her alleged disability onset
date (December 4, 2008) and 60 years old on her date last
insured (March 31, 2014). She has a high school education and
past relevant work as a claims technician and a claims
adjuster (Tr. 25).
December 4, 2008, David K. Lee, M.D., evaluated the plaintiff
at her workers' compensation carrier's request for
complaints of left hand pain, numbness, and tingling. The
plaintiff also complained of left shoulder pain and knee
problems. Dr. Lee noted that the plaintiff had fallen at work
and had landed on her hands and knees. Dr. Lee found the
plaintiff to have point tenderness over the first dorsal
compartment in her wrist and a positive Finkelstein's
test. Her knees showed some pain anteriorly with range of
motion. Her left shoulder showed some tenderness anteriorly
with a positive impingement sign. Dr. Lee diagnosed bilateral
de Quervain's tenosynovitis, bilateral knee contusions,
and left shoulder tendinitis. Dr. Lee recommended splinting,
anti-inflammatory medication, occupational therapy, and an
MRI. Dr. Lee indicated that the plaintiff should be
restricted to light duty with no lifting over five pounds, no
pushing or pulling over five pounds, ground level work only,
and no repeated bending, stooping, or squatting (Tr. 834-36).
December 8, 2008, S. Wendell Holmes. Jr., M.D., evaluated the
plaintiff for complaints of bilateral hand, knee, and
shoulder pain from an incident where she slipped and fell at
work. Associated complaints included pain that worsened with
gripping, lifting, and general use of her hands. The
plaintiff stated her anterior knee pain was getting better,
but it was worsened by walking. She complained that her
shoulder pain was becoming the biggest and most painful
problem for her. On physical examination, she had pain over
the first dorsal compartment of both hands but had full range
of motion. She had minor pain on the anterior side of her
knees and moderate tenderness over medial compartments. The
plaintiff had full range of motion of her shoulders with mild
impingement signs and mild pain with resisted abduction
bilaterally. Dr. Holmes diagnosed bilateral de Quervain's
tenosynovitis, resolving bilateral anterior knee contusions,
and bilateral shoulder pain post fall. He administered
steroid injections into her wrists and prescribed Feldene.
Dr. Holmes wrote for the plaintiff to be restricted to light
duties (Tr. 288-90).
December 9, 2008, Charles M. Butler, M.D., evaluated the
plaintiff for followup of infiltrating ductal right breast
carcinoma. Dr. Butler continued her on Arimidex and Effexor,
and he flushed her port (Tr. 373).
March 19, 2009, Bhavesh R. Amin, M.D., evaluated the
plaintiff for pain in her right lower extremity with
associated numbness. She had a positive straight leg raise.
Dr. Amin diagnosed low back pain with radiculopathy and
abdominal pain and swelling. He ordered an MRI of the
lumbosacral spine and gave the plaintiff a prescription for
Naproxen (Tr. 352).
March 27, 2009, the plaintiff had an MRI of her lumbosacral
spine, which was unremarkable (Tr. 356).
April 9, 2009, the plaintiff had a CT scan of her abdomen
that showed a small hernia just to the right of midline above
her umbilicus. It also showed a much larger right-sided
abdominal wall hernia that extended into the right anterior
pelvic quadrant as well as a gallstone (Tr. 354-55).
April 14, 2009, Dr. Butler evaluated the plaintiff for
followup of infiltrating ductal right breast carcinoma. Dr.
Butler continued Arimidex and noted that the plaintiff wished
to taper off of Effexor (Tr. 372).
April 15, 2009, Dr. Lee evaluated the plaintiff for followup
of bilateral knee, wrist, and shoulder pain. Dr. Lee
diagnosed bilateral de Quervain's tenosynovitis,
bilateral knee contusions, and bilateral shoulder contusions.
The plaintiff reported receiving some injections by Dr.
Holmes that had helped but were starting to wear off. She
reported feeling some clicking and popping in both knees, and
she continued to feel a sharp pain in both shoulders. Dr. Lee
ordered occupational and physical therapy and started her on
Lyrica (Tr. 839).
April 16, 2009, Dr. Amin evaluated the plaintiff and reviewed
her recent diagnostic tests. Dr. Amin diagnosed back pain and
hernias. He referred her for a surgical consultation (Tr.
April 30, 2009, Dr. Holmes evaluated the plaintiff in
followup for bilateral shoulder pain with the left worse than
the right. Physical examination showed 160 degrees of
elevation both sides, actively and passively. She had
positive Hawkins and Neer impingement signs bilaterally. She
had weak external rotation and scaption of left worse than
right. She had bilateral trigger thumbs. Dr. Holmes diagnosed
bilateral shoulder pain and weakness. He ordered an MRI of
both shoulders to rule out rotator cuff injury (Tr. 287).
6, 2009, Anil J. Kudchadkar, M.D., evaluated the plaintiff
for recurrent incisional hernia and gallstone disease. She
reported several weeks of right upper quadrant pain. Dr.
Kudchadkar noted that the plaintiff was obese. He diagnosed
gallstone disease and abdominal hernia with recurrent
incisional hernia, and he ordered diagnostic testing (Tr.
14, 2009, the plaintiff had an abdominal ultrasound, which
showed cholelithiasis with a single large calculus without
evidence of cholecystitis and slight dilation of the common
bile duct measuring approximately six millimeters (Tr. 353).
21, 2009, Dr. Lee evaluated the plaintiff for followup of
pain in her wrists, knees, and shoulders. Physical
examination showed pain along the first dorsal compartment of
her thumb and positive impingement signs of her shoulders.
Dr. Lee diagnosed bilateral de Quervain's tenosynovitis,
bilateral knee contusions, and bilateral shoulder
impingement. Dr. Lee ordered formal hand therapy and an MRI
of both shoulders (Tr. 840).
3, 2009, the plaintiff had a mammogram, which showed benign
heterogeneously dense fibroglandular tissue (Tr. 380-81).
August 6, 2009, the plaintiff underwent a repair of recurrent
incarcerated incisional hernia with Peridex mesh (Tr.
August 25, 2009, Dr. Butler evaluated the plaintiff for
followup of infiltrating ductal right breast carcinoma. She
complained of continued hot flashes and hair loss. Dr. Butler
continued Arimidex and flushed the plaintiff's port (Tr.
August 27, 2009, Dr. Lee evaluated the plaintiff for followup
of bilateral wrist and hand pain. Physical examination showed
pain along the first dorsal compartment, a positive
Finkelstein's test, and a nodule on the A1 pulley. Dr.
Lee diagnosed bilateral de Quervain's tenosynovitis and
left thumb trigger. Dr. Lee recommended surgery to which the
plaintiff agreed (Tr. 841).
September 18, 2009, the plaintiff underwent a right wrist de
Quervain's tenosynovitis release (Tr. 326-27). On
September 29, 2009, Dr. Lee evaluated the plaintiff for
followup of the release surgery. The plaintiff indicated that
she was doing better. Dr. Lee removed her sutures and placed
her in a Velcro thumb spica splint. He ordered occupational
therapy for her wrist and indicated that shoulder surgery
might be required (Tr. 842). On October 27, 2009, the
plaintiff had continued complaints of left wrist and trigger
thumb discomfort. Dr. Lee diagnosed status-post right de