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 September 11, 2013, alleging
that she became unable to work on May 1, 2012. The
application was denied initially and on reconsideration by
the Social Security Administration. On August 5, 2014, the
plaintiff requested a hearing. The administrative law judge
(“ALJ”), before whom the plaintiff and Thomas C.
Neil, an impartial vocational expert,  appeared via a
video hearing on March 15, 2016, considered the case de
novo and, on May 4, 2016, found that the plaintiff was
not under a disability as defined in the Social Security Act,
as amended (Tr. 26-44). 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 June 2, 2017 (Tr. 1-4). The plaintiff then filed
this action for judicial review.
making the determination that the plaintiff is not entitled
to benefits, the Commissioner has adopted the following
findings of the ALJ:
(1) The claimant meets the insured status requirements of the
Social Security Act on March 31, 2017.
(2) The claimant has not engaged in substantial gainful
activity since May 1, 2012, the alleged onset date (20 C.F.R.
§ 404.1571 et seq).
(3) The claimant has the following severe impairments:
cervical spondylosis and history of right shoulder
impingement (20 C.F.R. § 404.1520(c)).
(4) The claimant does not have an impairment or combination
of impairments that meets or medically equals 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,
(5) After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform medium work as defined in 20
C.F.R. § 404.1567(c) except that she cannot climb
ladders, ropes, or scaffolds; she can occasionally reach
overhead with the right arm; and she must avoid working at
unprotected heights or around hazardous machinery.
(6) The claimant is capable of performing past relevant work
as a school bus driver, teacher aide, office clerk, and
receptionist. This work does not require 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, from May 1, 2012, through the date
of this decision (20 C.F.R. § 404.1520(g)).
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 35 years old on her alleged disability onset
date (May 1, 2012) and 39 years old at the time of the
ALJ's decision (May 4, 2016). She has a high school
education and past relevant work as a school bus driver,
teacher aide, office clerk, and receptionist (Tr. 42-43).
24, 2009, the plaintiff saw her primary care physician,
Daniel E. DeCamps, M.D., at Pee Dee Family Practice for
headaches. She was unable to sleep, her arms and legs ached,
and she could not get comfortable. On examination, her blood
pressure was slightly elevated, and she had some tenderness
in her trapezius muscles. She had full range of motion of her
neck (Tr. 354). She returned for a three week followup on
August 7, 2009, with complaints of headaches and spasms in
her trapezius muscles (Tr. 353).
March 10, 2010, the plaintiff saw Dr. DeCamps for headaches
and neck pain. She had full range of motion of her neck with
some tenderness. Her trapezius muscles had some spasm. Dr.
DeCamps assessed her with neck pain with radiculopathy and
headache (Tr. 352). An MRI taken on March 12, 2010, was
normal (Tr. 350). On June 2 and 9, 2010, the plaintiff was
seen for diffuse muscle aches and pains, and fibromyalgia
symptoms due to myofascial trigger points. She was assessed
with sinusitis and cervical muscle spasms (Tr. 348-49). On
September 23, 2010, she was seen for evaluation and followup
of supraventricular tachycardia (“SVT”).
Examination was unremarkable, and she was assessed with SVT,
frontal headaches, and photophobia (Tr. 345). She returned on
September 24th with severe headaches and elevated
blood pressure. Dr. DeCamps started her on Nadalol to lower
her blood pressure and prevent headaches (Tr. 344). On
October 1 and 15, 2010, she had continued headaches,
myofascial trigger points in her back, insomnia, tachycardia,
fatigue, muscle aches, muscle spasms, and obstipative type
symptoms. Restoril helped her sleep significantly, and
Meloxicam helped with a lot of her aching and soreness. Dr.
DeCamps prescribed Amitiza for the obstipation. He wrote to
keep her out of work until further notice (Tr. 341-42).
April 8, 2011, the plaintiff saw Dr. DeCamps for follow up of
cervical strain/neck pain and shoulder discomfort. On
examination, she had diffuse tenderness in the shoulder area
and in the suprascapular area. She had no myofascial trigger
point. She had low back pain down to the trochanteric bursa
area and down the side of her leg. Physical therapy was
ordered (Tr. 340). On April 20, 2011, she had no improvement
with cervical and lumbar pain. She could not get comfortable
at night to sleep and felt as if her medicines were not
helping anymore. On examination, she had some cervical
tenderness, increased muscle tone to palpation extending into
the suprascapular area, right worse than left. She continued
to have some right paralumbar tenderness extending into the
right trochanteric area with some pain over the right
trochanteric bursa to palpation (Tr. 339). On May 4, 2011,
the plaintiff's cervical and lumbar pain were worse after
physical therapy, and she still had knots in her neck.
Examination showed continued mild cervical and lumbar
tenderness to palpation, paracervical nodularity, possibly
myofascial trigger points, some paralumbar tenderness to
palpation, and increased muscle tone (Tr. 338).
18, 2011, the plaintiff reported to Dr. DeCamps that her
condition was the same. She had numbness and discomfort in
her right shoulder, left suprascapular pain, and pain due to
overuse of her left hand because she could not use her right
hand. Examination revealed suprascapular myofascial trigger
points, tenderness in right and left suprascapula, and
tenderness in cervical area (Tr. 337). On June 22, 2011, in a
followup for cervical sprain, the plaintiff reported that
physical therapy helped. She was pain free for a couple of
hours or a day. ...