United States District Court, D. South Carolina
V. Hodges United States Magistrate Judge
appeal from a denial of social security benefits is before
the court for a final order pursuant to 28 U.S.C. §
636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of
Honorable Timothy M. Cain, United States District Judge,
dated October 10, 2017, referring this matter for
disposition. [ECF No. 8]. The parties consented to the
undersigned United States Magistrate Judge's disposition
of this case, with any appeal directly to the Fourth Circuit
Court of Appeals. [ECF No. 4].
files this appeal pursuant to 42 U.S.C. § 405(g) of the
Social Security Act (“the Act”) to obtain
judicial review of the final decision of the Commissioner of
Social Security (“Commissioner”) denying the
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 court affirms.
December 13, 2013, Plaintiff filed an application for DIB in
which she alleged her disability began on March 1, 2013. Tr.
at 168-69. Her application was denied initially and upon
reconsideration. Tr. at 62-70 and 74-85. On October 11, 2016,
Plaintiff had a video hearing before Administrative Law Judge
(“ALJ”) Carl B. Watson. Tr. at 35-61 (Hr'g
Tr.). The ALJ issued an unfavorable decision on March 2,
2017, finding that Plaintiff was not disabled within the
meaning of the Act. Tr. at 8-34. 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 October
9, 2017. [ECF No. 1].
Plaintiff's Background and Medical History
was 64 years old at the time of the hearing. Tr. at 38. She
completed high school and obtained a licensed practical
nursing (“LPN”) degree. Id. at 42. Her
past relevant work (“PRW”) was as an insurance
clerk and a LPN. Tr. at 40. She alleges she has been unable
to work since June 2013. Tr. at 39.
March 1, 2013, Emergency Medical Services (“EMS”)
took Plaintiff to the emergency department at Carolinas
Hospital System for treatment of a scalp laceration. Tr. at
303-11. Plaintiff reported she was injured at work when an
angry patient pushed her into a door frame. Tr. at 303. The
treating physician, Dr. Scott Burns (“Dr.
Burns”), noted the laceration was two centimeters long,
linear, extended through the dermis into the subcutaneous
tissue, and had sharp, clean margins and minimal bleeding.
Id. He noted there was no tendon or vascular
involvement. Id. Dr. Burns closed the wound with
three staples and sutures. Id. He prescribed Vicodin
and ibuprofen for pain. Tr. at 304.
March 1, 2013, Plaintiff also saw Dr. Maria Perez-Garcia
(“Dr. Perez-Garcia”) at Carolinas Urgent Care and
Occupational Health Center. Tr. at 334-36. Dr. Perez-Garcia
noted a head contusion with laceration on the left parietal
area. Tr. at 334. Plaintiff reported losing consciousness for
a few seconds after the injury and complained of neck pain
and headache. Id. Plaintiff stated the pain from her
headache was a 6 out of 10 and did not radiate to her upper
extremity. Id. She denied tingling, numbness, or
weakness in her upper and lower extremities. Id. On
examination, Dr. Perez-Garcia noted Plaintiff had tenderness
to palpation (“TTP”) on the left side of her neck
and pain with range of motion (“ROM”) on the left
side and posterior neck. Id. Dr. Perez-Garcia
indicated Plaintiff's upper extremity, pupils, nose,
ears, throat, lungs, heart, abdomen, and neurologic exam were
all normal. Id.
received a plain x-ray of her cervical spine. Tr. at 335. The
reviewing radiologist, Dr. Steven Creedman (“Dr.
Creedman”), noted moderate C5-6 interspace narrowing
with small dorsal and bilateral uncovertebral spurs and
assessed C5-6 degenerative disc disease (“DDD”).
Id. Dr. Perez-Garcia stated Plaintiff's x-ray
was normal. Tr. at 334. She assessed status post-fall with
head contusion and laceration on the scalp (that was repaired
with three staples and neck pain). Id. She also
noted loss of consciousness was questionable. Id.
Dr. Perez-Garcia opined Plaintiff could return to work the
following day, but should be restricted to desk work and
should not handle patients without assistance. Id.
She referred her for a brain computerized tomography
(“CT”) scan. Id.
March 6, 2013, Plaintiff received a head CT. Tr. at 396. Dr.
Charles Parke found mild frontal periventricular white matter
low attenuation and a small area of low attenuation in the
right anterior limb internal capsule. Id. He noted
these findings were most suspicious for mild small vessel
ischemic disease and that demyelination seemed less likely.
Id. He did not find evidence of posttraumatic
contusion, mass, or hemorrhage intracranially. Id.
He noted the left parietal scalp laceration with small
staples were in place and indicated he did not see any
underlying hematoma or calvarial fracture. Id.
March 8, 2013, Plaintiff had a follow-up appointment with Dr.
Perez-Garcia. Tr. at 332-33. Plaintiff complained of headache
in the area of the laceration and pain in her right shoulder,
posterior neck, and lumbar area. Tr. at 332. She denied
tingling, numbness, or weakness in her extremities and denied
vision problems. Id. Dr. Perez-Garcia indicated
Plaintiff's head CT scan was normal. Id. On
examination, Dr. Perez-Garcia noted Plaintiff had mild TTP of
the posterior neck and TTP on the top of the shoulder and the
trapezial muscle, but full ROM and very minimal pain with
ROM. Id. She assessed status post-fall, head
contusion, laceration of the scalp, neck pain, lumbar pain,
and local reaction to a tetanus shot. Id. She
continued to restrict Plaintiff to desk work and no patient
handling without assistance. Id.
March 11, 2013, Dr. Perez-Garcia continued Plaintiff's
work restrictions and prescribed prednisone. Tr. at 331. She
noted Plaintiff's diagnoses included status post-fall,
head contusion and laceration, neck pain, lumbar sprain,
headache, and local reaction to tetanus shot. Id.
March 18, 2013, Plaintiff returned to Dr. Perez-Garcia. Tr.
at 329- 30. Plaintiff reported worsening lumbar pain
radiating to the posterior right leg with tingling sensation.
Tr. at 329. She denied weakness. Id. She said the
prednisone helped, but the pain returned. Id. She
also continued to complain of neck pain rated 4 out of 10.
Id. On examination, Dr. Perez-Garcia noted Plaintiff
had no TTP or pressure to her neck and she had full ROM and
no pain with ROM. Id. Plaintiff had no TTP to her
lumbar area, but did have pain with ROM. Id. Her
reflexes, sensitivity, and muscle strength were normal.
Id. Dr. Perez-Garcia referred Plaintiff for an MRI
of her lumbar spine and continued to restrict her to desk
work only. Id. She assessed status post-fall with
head contusion, neck sprain, lumbar sprain, and paresthesias
of the right leg. Id. She prescribed Motrin and
March 21, 2013, Plaintiff began seeing Dr. Jimena C. Burnett
(“Dr. Burnett”) at McLeod Physician Associates.
See Tr. at 416-18. Plaintiff reported her history of
hypertension and low back pain. Tr. at 416. She indicated she
had been taking her hypertension medication as directed and
had been responding to them well. Id. She complained
of pain in her lower back on the right side and numbness in
her right leg. Id. Plaintiff's medications
included Synthroid, Aspir-81, Enalapril Maleate, and
Ibuprofen. Id. Plaintiff's blood pressure was
164/84. Tr. at 417. Dr. Burnett assessed essential
hypertension, colon cancer screening, hypothyroid, annual
physical exam, lipid screening, neck pain, and back pain. Tr.
at 418. She increased Plaintiff's Enalapril Maleate
Tablet dosage and ordered a comprehensive metabolic panel.
March 25, 2013, in another follow-up appointment with Dr.
Perez-Garcia, Plaintiff reported her headache had improved
and was intermittent, but she continued to experience
tinnitus in both ears. Tr. at 327. Plaintiff also reported
continued posterior non-radiating neck pain rated 4 out of
10. Id. She rated her lumbar pain 3 out of 10 and
indicated it continued to radiate to the lateral right thigh.
Id. Dr. Perez-Garcia noted having ordered an MRI,
but it was still pending. Id. She noted Plaintiff
appeared uncomfortable, but not in acute distress.
Id. On examination of Plaintiff's neck,
Plaintiff experienced TTP posteriorly and at the base of her
neck, but only on the soft tissue. Id. Plaintiff had
full ROM and no pain with ROM. Id. Plaintiff had no
TTP on her lumbar spine, but had pain with flexion,
extension, and lateral movement radiating to her right leg.
Id. Dr. Perez-Garcia's assessment did not
change. Id. She continued to restrict Plaintiff to
desk work and prescribed diclofenac. Id.
March 27, 2013, Plaintiff received an MRI of her lumbar
spine. Tr. at 397. Dr. Charles Parke (“Dr.
Parke”) noted very mild convex curvature in the upper
lumbar spine apex at the L1 level; moderate marked disc
degeneration and moderate disc narrowing at ¶ 11-12 with
circumferential disc bulging, greatest anteriorly; posterior
disc bulging causing mild thecal sac effacement and mild
right foraminal stenosis, but no focal cord compression;
minor left sided annular bulging extending to the foramen and
mild facet arthrosis at ¶ 4-5; mild disc degeneration
peripherally, left anterior and left lateral annular bulging
with mild left foraminal narrowing due to disc bulge at
¶ 2-3 and L3-4; and a small annular fissure on the left
side at ¶ 2-3. Id. His impression included no
evident fractures or lumbar compressive discopathy; moderate
to advanced T11-12 disc degeneration with chronic
circumferential annular bulging, but no defined cord
compression and mild right foraminal narrowing due to
asymmetric disc bulging and spondylosis; and left-sided mild
disc degeneration and annular bulging at ¶ 2-3 and L3-4.
April 1, 2013, Plaintiff returned to Dr. Perez-Garcia. Tr. at
324. Plaintiff rated her neck pain 4 out of 10, but only to
touch, and Dr. Perez-Garcia noted Plaintiff had full ROM in
her neck and no pain with ROM. Id. Plaintiff
continued to report a posttraumatic headache. Id.
She indicated her lumbar pain as 4 out of 10 and radiating to
the right leg with numbness. Id. Dr. Perez-Garcia
stated a lumbar spine MRI revealed DDD, but no herniated disc
or other acute injury. Id. She noted Plaintiff had
lumbar pain with ROM on flexion, extension, and lateral
movement. Id. Her assessment did not change.
Id. She continued to restrict Plaintiff to desk work
and referred her to four weeks of physical therapy.
April 8, 2013, Dr. Perez-Garcia noted Plaintiff was
improving. Tr. at 321. Plaintiff reported her neck pain had
improved with Flexeril and Voltaren. Id. She
described her head pain as a frontal headache that started on
the right side and went to the left side and denied
neurological symptoms. Id. Dr. Perez-Garcia noted
Plaintiff's uncontrolled blood pressure may be
contributing to her headaches. Id. Plaintiff
indicated her right leg pain was worse when sitting and
reported stiffness after long periods of immobility.
Id. She also complained of constant numbness in her
first two toes and low back pain that worsened with movement.
Id. An examination of Plaintiff's neck showed
point tenderness over C7 and no ROM restrictions.
Id. A lumbar examination revealed pain with movement
around L1-L2. Id. Dr. Perez-Garcia continued to
restrict Plaintiff to desk work, recommended she not take
Voltaren on a daily basis, and recommended she follow up with
her primary care physician about her blood pressure, as it
may be contributing to her headache. Id.
April 9, 2013, Plaintiff attended her first physical therapy
session at Progressive Physical Therapy. Tr. at 339. On her
medical history form, Plaintiff indicated her pain was aching
and constant. Tr. at 353. She stated leaning, sitting, and
laying down made her pain feel worse. Id. She rated
her pain as 8 out of 10, noted her worst pain over the past
30 days had been 10 out of 10, and indicated the least pain
she had experienced over the prior 30 days was 4 out of 10.
Id. The therapist noted Plaintiff had symptoms
consistent with a differential diagnosis of low back strain
and cervicogenic headaches and recommended she continue
physical therapy two to three times a week for four weeks.
Tr. at 339.
April 11, 2013, Plaintiff returned to physical therapy. Tr.
at 340. Plaintiff reported a little extended relief after her
last session. Id.
April 15, 2013, Plaintiff followed up with Dr. Perez-Garcia.
Tr. at 319. She reported continued sharp, intermittent
headache pain in the left temporal area and shooting to the
right frontal area. Id. She rated her headache pain
4 out of 10. Id. Plaintiff continued to complain of
pain across her lumbar area, with numbness and pain in her
right leg and right toe. Id. She rated this pain 4
out of 10. Id. She reported continued neck pain with
flexion and rated that pain 3 out of 10. Id. She
complained that flexing her neck caused headaches.
Id. Dr. Perez-Garcia noted Plaintiff's blood
pressure was still elevated, but her family doctor was
working on changing her medication. Id. Plaintiff
reported her two physical therapy sessions had helped a
little, especially with her right leg pain. Id. On
examination, Dr. Perez-Garcia found Plaintiff had mild
tenderness on the posterior right side of her neck, full ROM,
and some pain with flexion. Id. Plaintiff had mild
tenderness on the mid and upper lumbar area and across the
lumbar spine; normal muscle sprain, reflexes, and
sensitivity; and pain with ROM. Id. Dr. Perez-Garcia
continued to restrict Plaintiff to desk work only. Tr. at
320. She assessed status post-fall with head and brain
contusion, neck sprain, lumbar sprain, and posttraumatic
headache. Tr. at 319.
April 16, 2013, Plaintiff told her physical therapist she had
done her exercises at home, but not every day, and indicated
the Voltaren seemed to numb the pain. Tr. at 341.
April 18, 2013, Plaintiff returned to physical therapy and
reported experiencing a lot of pressure in her neck. Tr. at
342. She indicated a decrease in her headache pain at the end
of her session. Id.
April 22, 2013, Plaintiff told Dr. Perez-Garcia she was
feeling about the same. Tr. at 316. She stated physical
therapy had been helping. Id. She reported
intermittent pain behind her eyes, alternating from the left
to the right eye. Id. Plaintiff's current
medications included Enalapril, which Dr. Perez-Garcia noted
was not effectively controlling Plaintiff's blood
pressure, Synthroid, aspirin, Motrin, and Flexeril.
Id. On examination, Dr. Perez-Garcia indicated
Plaintiff seemed pleasant and comfortable; had TTP on the
left and posterior neck; had full ROM in her neck, but
complained of pain with ROM; and complained of severe pain to
palpation of her lumbar area and numbness of the right leg.
Id. Plaintiff had normal ambulation and normal
reflexes and sensitivity of the lower extremity. Id.
Dr. Perez-Garcia continued to restrict Plaintiff to desk work
only. Id. She assessed posttraumatic headache, neck
sprain, and lumbar sprain. Id. She recommended
discontinuing non-steroid anti-inflammatory drugs due to
Plaintiff's hypertension. She prescribed Lortab and
instructed Plaintiff to continue taking Tylenol and Flexeril
and referred her to a neurologist for her headaches.
April 23, 2013, Plaintiff reported her pain returned about
two hours after her last physical therapy session. Tr. at
April 26, 2013, in physical therapy, Plaintiff stated she
experienced increased pain with increased pressure on her
right lower extremity. Tr. at 344. She again reported
decreased headache pain after therapy. Id.
April 29, 2013, Plaintiff returned to Dr. Perez-Garcia. Tr.
at 314. Plaintiff continued to report head pain, describing
it as piercing and intermittent and rating it a 6 out of 10.
Id. She also reported a headache across the left
side of her head, rated 4 out of 10. Id. She denied
vision and hearing problems. Id. Dr. Perez-Garcia
noted having referred Plaintiff to a neurologist for her
posttraumatic headache. Id. Plaintiff complained of
severe posterior pain in her neck, not radiating to her upper
extremities. Id. She reported improved pain in her
lumbar area and indicated the pain was intermittent with
movement and rated 4 out of 10. Id. She continued to
complain of pressure and numbness in her right leg that had
not improved. Id. Dr. Perez-Garcia noted Plaintiff
had limited ROM in her lumbar spine. Id. She
assessed posttraumatic headache and neck and lumbar sprain
and noted Plaintiff's high blood pressure remained
uncontrolled. Id. She continued to restrict
Plaintiff to desk work only. Id.
April 30, 2013, Plaintiff told the physical therapist she had
been really sore. Tr. at 345. She reported her headache
decreased initially after her last session, but then returned
about one hour later and lasted longer. Id.
3, 2013, Plaintiff's physical therapist noted she
experienced increased headache pain throughout all of her
cervical spine activities, especially stretches. Tr. at 346.
5, 2013, Plaintiff told her physical therapist she was not
doing well and felt like she had been hit. Tr. at 347. She
reported decreased pain following her session. Id.
9, 2013, Plaintiff reported her back was feeling better, but
her neck had been really bothering her, and her leg still
felt heavy. Tr. at 348. She reported decreased headache and
neck pain following her physical therapy session.
13, 2013, Dr. Perez-Garcia continued Plaintiff's work
restriction. Tr. at 313. She noted Plaintiff's diagnoses
included neck and lumbar sprain and posttraumatic headache
and indicated Plaintiff was to see the neurologist that day.
14, 2013, a physical therapy assistant indicated
Plaintiff's compliance with her home exercise plan was
fair; her pain was aggravated when she turned her head or
walked more than ten feet; and Plaintiff could complete 20
squats and could push and pull a sled with 45 pounds for
three minutes with some increased discomfort and headache
pain. Tr. at 379. Her report included an Oswestry
low back pain questionnaire that Plaintiff apparently
completed. Tr. at 380. On the questionnaire, Plaintiff
indicated pain medication provided her with little relief
from pain; she could take care of herself normally without
causing increased pain; she could lift only very light
weights; pain prevented her from walking more than a quarter
mile, sitting for more than 10 minutes, and standing for more
than 30 minutes; she could sleep well only by using pain
medication; pain prevented her from going out very often,
restricted her travel to short, necessary journeys under 30
minutes, and prevented her from doing anything but light
records from Progressive Physical Therapy also include an
undated Oswestry neck questionnaire, on which Plaintiff
indicated her pain was mild at the moment; she could look
after herself normally without causing extra pain; she could
lift only very light weights; she could not read as much as
she wanted because of moderate pain in her neck; she had
headaches almost all the time; she had a lot of difficulty
concentrating when she wanted to; she could not do her usual
work; she could not drive her car as long as she wanted
because of moderate pain in her neck; her sleep was
moderately disturbed; and she could hardly do any
recreational activities because of pain in her neck. Tr. at
17, 2013, Plaintiff returned to physical therapy. Tr. at 350.
She reported neck pain following her last session and
expressed concern there might be a more serious problem.
Id. She complained of increased pulling and
tenderness in her cervical spine. Id.
20, 2013, Dr. Perez-Garcia indicated Plaintiff's work
restriction would continue until her neurologist indicated
otherwise. Tr. at 312. She discharged Plaintiff with
diagnoses of neck sprain, lumbar sprain, right leg numbness,
and posttraumatic headache. Id.
3, 2013, Dr. George Sandoz (“Dr. Sandoz”) of
Grand Strand Spine and Neuro examined Plaintiff for
complaints of headache, neck pain, back pain, and loss of
consciousness. Tr. at 558-60. Plaintiff indicated her
headaches were moderate to severe; had been occurring daily
for three months; we located in the frontal left, frontal
right, and occipital, with radiation to posterior. Tr. at
558. She reported debilitating pressure, mostly during the
daytime, aggravated by head position, noise, and stress.
Id. She reported associated blurred vision, memory
loss, neurological symptoms, performance changes, stiff neck,
and visual aura, but denied dizziness. Id. Plaintiff
described her neck pain as daily moderate aching and burning
and located in the bilateral posterior neck with radiation to
the bilateral head and upper arm. Id. She indicated
the pain was aggravated by flexion, hyperextension, kneeling,
walking, and working, and that she experienced relief from
massage. Id. She noted associated symptoms of
trouble sleeping, muscle spasm, and tenderness, and denied
bladder retention. Id. Plaintiff described her back
pain as moderate to severe, persistent, worsening, located in
the lower back, and radiating to the dermatome anteriorly.
Id. She noted her symptoms were aggravated by daily
activities and denied any relieving factors. Id.
Plaintiff reporting losing consciousness when she fell in
March and indicated associated symptoms of headache, memory
loss, and neurological symptoms and denied bladder
examination, Dr. Sandoz noted Plaintiff experienced muscle
spasms in both her cervical and lumbar spine. Tr. at 559. He
assessed headache, neck pain, back pain, and syncope.
Id. He ordered a brain MRI to evaluate the
possibility of a stroke and recommended Plaintiff continue
with light duty work and tramadol for her pain. Tr. at
4, 2013, Plaintiff canceled her physical therapy appointment,
stating she wanted to have additional tests done by a doctor
before continuing physical therapy. Tr. at 351.
19, 2013, Plaintiff's physical therapist discharged her
from physical therapy because she had been referred to a
specialist and was undergoing testing. Tr. at 369.
1, 2013, Dr. Stephen Gordin (“Dr. Gordin”)
administered an MRI of Plaintiff's cervical spine. Tr. at
398. Dr. Gordin noted some degenerative spurring off the
anterior aspect of the C4 vertebral body; a small central
disc protrusion mildly attenuating the ventral subarachnoid
space, but not touching the spinal cord, and bilateral facet
joint arthropathic changes at ¶ 4-5; bilateral facet
joint arthropathy, small disc bulge, and bilateral
arthropathic facet changes at ¶ 5-6; and small disc
bulge and bilateral facet joint arthropathy at ¶ 6-7.
Id. His impression included multilevel spondylitic
changes, but no focal disc herniation or severe central canal
stenosis; only fat noted beneath Plaintiff's marker, but
a well-defined lipoma not identified; and some heterogeneity
to the left thyroid lobe. Id.
9, 2013, Dr. Gordin administered an MRI of Plaintiff's
brain. Tr. at 399. Dr. Gordin noted an area of low signal in
the periventricular white matter on the right adjacent to the
anterior angle of the right lateral ventricle that was of low
signal on T1 sequence and bright on T2. Id. He
stated this suggested a small area of prior ischemia and
noted this seemed to correspond with Plaintiff's March 6,
2013 CT scan. Id. Dr. Gordin noted some foci on T2
hyperintensity in the left corona radiate and in the right
centrum semiovale that suggested gliosis from small vessel
ischemia. Id. The scan was otherwise unremarkable.
Id. His impression included evidence of chronic
ischemic changes affecting the brain. Id. He did not
find evidence of pathologic enhancement. Id. He
indicated white matter disease, which he opined was most
likely reflective of small vessel ischemia and was unlikely
to reflect demyelination because there were no associated
pathologic enhancements or mass effect to suggest any were
22, 2013, Plaintiff had a follow-up appointment with Dr.
Sandoz. Tr. at 555-57. Plaintiff indicated her neck pain had
worsened and was aggravated by driving, straining, Valsalva,
and working. Tr. at 555. She reported relief from narcotic
analgesics. Id. She reported the pain in her lower
back had radiated to the right foot and indicated pain
medications relieved her symptoms. Id. Plaintiff
reported associated symptoms of clumsiness, confusion, memory
difficulty, vomiting, and syncope. Id. On
examination, Dr. Sandoz indicated Plaintiff had muscle spasms
in her cervical and lumbar spine, mildly reduced ROM in her
cervical spine, and moderate pain with motion in her lumbar
spine. Tr. at 556. He noted Plaintiff had been compliant with
her medication and was responding to current treatment.
Id. Dr. Sandoz assessed post-trauma headache, late
effect of intracranial injury without mention, cervical
spondylosis without myelopathy, and lower back pain.
Id. He noted changes on her brain and neck MRI;
recommended neuropsychological testing, an EEG, a nerve
conduction study, and a lumbar spine MRI; and limited
Plaintiff to light duty with a 10 pound weight restriction.
August 15, 2013, Plaintiff returned to Dr. Sandoz. Tr. at
552-54. Dr. Sandoz continued to rate Plaintiff's headache
and back pain as moderate to severe. Tr. at 552. Plaintiff
reported experiencing headaches daily upon awakening.
Id. Dr. Sandoz noted muscle spasm in Plaintiff's
cervical and lumbar spine. Tr. at 553. He assessed posttrauma
headache, cervical disc displacement without myelopathy, late
effect of intracranial injury without mention, and back pain.
Id. He recommended Plaintiff continue taking Ultram
and noted results of an epidural steroid injection.
Id. He continued to limit Plaintiff to light duty.
September 26, 2013, Dr. David Scott (“Dr. Scott”)
at Moore Orthopedics began treating Plaintiff. Tr. at 540-41.
Plaintiff reported back, neck, and leg pain since her March
2013 injury. Tr. at 540. She also complained of constant
tinnitus and headaches. Id. Dr. Scott did not note
any abnormalities on physical examination. Id. He
reviewed Plaintiff's cervical spine MRI and noted some
areas of modest neuroforaminal stenosis, but nothing that
approached a severe level or that he would expect to manifest
in substantial symptoms. Tr. at 541. He took plain films of
the cervical and lumbar spine during the visit. Id.
The cervical spine films showed some DDD and anterior
spurring with relative reversal of the normal cervical
lordosis. Id. The lumbar spine films showed some
modest DDD and a little facet arthrosis, but no impressive
listhesis, fracture, DDD, or other impressive pathology.
Id. Dr. Scott recommended Plaintiff see an ENT for
her headaches and tinnitus. Id. He indicated he did
not see anything overwhelming in her cervical spine, but
noted epidural injections may be indicated if her symptoms
did not resolve. Id.
October 3, 2013, Plaintiff returned to Dr. Scott with her
lumbar spine MRI. Tr. at 539. Dr. Scott examined Plaintiff
and noted good cervical ROM and a little bit of pain in the
soft tissues around the neck in the paraspinal muscles.
Id. Dr. Scott reviewed the cervical and lumbar MRIs
and did not see anything overly impressive concerning central
canal or neural foraminal stenosis. Id. He stated he
did not see any reason why Plaintiff could not return to
work, but noted Plaintiff was adamant that she could not
work. Id. Plaintiff's insistence that she could
not work made Dr. Scott uncomfortable returning her to a
place where she was charged with caring for people, so he
indicated he would keep her out of work or at least impose
lifting, pulling, and pushing restrictions to keep her from
having responsibility for lifting or pushing patients.
October 11, 2013, to November 22, 2013, Plaintiff was treated
by Dr. Leah Hamoy (“Dr. Hamoy”) at Dynamic
Physical Therapy of Florence. Tr. at 338, 446, 451-54, 457,
459, 464, 466, 468, 470, 472, 477, 479, 480, 482, 483-85,
486-88. Dr. Hamoy noted Plaintiff had made progress and
reported decreased pain following treatments, but her
subjective complaints continued to fluctuate, even without
strenuous activities. Id.
October 24, 2013, Plaintiff returned to Dr. Scott for an
evaluation of her right hip. Tr. at 537-38. Plaintiff noted
her back still hurt and her neck was causing her some
discomfort, but she wanted Dr. Scott to pay closer attention
to her hip. Tr. at 537. Dr. Scott's physical examination
was unremarkable. Id. He obtained plain films of the
right hip and found no signs of fracture, dislocation, or
other bony abnormality; no evidence of femoral head, neck, or
shaft fracture; and no impressive overwhelming signs of
arthritis. Id. Dr. Scott noted Plaintiff seemed
generally dissatisfied with her progress and said he would
seek another opinion regarding possible interventional
procedures. Tr. at 537-38.
October 29, 2013, Plaintiff returned to Dr. Sandoz. Tr. at
549-51. She rated her headaches as moderate to severe and her
neck pain as moderate and indicated that both problems had
worsened. Tr. at 549. Plaintiff continued to complain of back
pain and memory loss and reported moderate, persistent
dizziness. Id. Plaintiff described the dizziness as
an unstable horizon, occurring spontaneously, aggravated by
turning, and relieved by changing position. Id. She
reported experiencing associated symptoms of headache and
paresthesias, but denied diplopia. Id. On
examination, Dr. Sandoz indicated muscle spasm in
Plaintiff's cervical spine, but found no lumbar spine
tenderness and normal mobility and curvature. Tr. at 550. He
assessed posttrauma headache, dizziness, lumbar disc
displacement, cervical disc displacement without myelopathy,
and late effect of intracranial injury without mention.
Id. He noted Plaintiff's headache was not
responding to medication and prescribed Elavil and Imitrex.
Id. He indicated Plaintiff had seen an ENT, but they
were awaiting a neuropsychological evaluation to determine if
further treatment was warranted for memory loss. Id.
November 25, 2013, Dr. Amit Sanghi (“Dr. Sanghi”)
at South Carolina Diagnostic Imaging administered a brain
MRI. Tr. at 435-36. He noted Plaintiff continued to
experience headaches on the right side of her head, hearing
loss in her right ear, blurred vision, and changes in her
speech. Tr. at 435. The MRI showed mild diffuse cerebral
atrophy, which Dr. Sanghi noted may be age-related, and
multiple punctate FLAIR signal abnormalities within the deep
white matter of the brain in the basal ganglia and
distribution on T2 FLAIR sequences. Id. He found no
evidence of mass at the costophrenic (“CP”)
angle, specifically the seventh and eighth cranial nerves.
November 27, 2013, Plaintiff saw Dr. John Clavet (“Dr.
Clavet”) at Moore Orthopedics for a second opinion
regarding her neck and lower back pain. Tr. at 533-36.
Plaintiff described her neck pain as located on the left side
of the neck at the base of the neck, left upper trap area,
5/10 in severity, aching and throbbing in characteristic. Tr.
at 533. She indicated she did not have pain radiating down
the arms and the pain was aggravated with flexion,
particularly with looking down to read. Id. She
reported topical heat, massage, and a TENS unit provided
relief and that physical therapy had been helpful.
Id. Plaintiff described her lower back pain as
right-sided lumbosacral back pain with a radiating component
down the back of the leg to the foot, sharp pain, 4/10 in
severity, aggravated with lying in bed, and alleviated with
massage and a TENS unit. Id. She reported she
returned to work on light duty from April 1st through June
8th, but was subsequently told no further light duties were
Clavet reviewed Plaintiff's radiographs. Tr. at 533-34.
He noted Plaintiff's October 21, 2013 hip films showed
enthesopathic changes at bilateral ASIS; minimal inferior
changes with preservation of joint spaces at the SI joints;
unremarkable bilateral hips with intact femoral acetabular
joint spacing; and unremarkable frog-leg view of the right
hip. Id. Her lumbar spine films from September 2013
did not show any traumatic changes or evidence of
spondylolisthesis or spondylolysis, and intervertebral disc
heights were well maintained. Tr. at 534. Her lumbar spine
MRI from March 2013 showed intact intervertebral disc heights
and minimal degenerative disc changes; patent canal at all
levels; mild to moderate left neuroforaminal narrowing; and
no indication of any high-grade stenosis at any level.
Id. Plaintiff's September 2013 plain films of
the cervical spine showed straightening of the cervical spine
with loss of normal cervical lordosis, mild to moderate
spondylitic changes centered at ¶ 5-6, and narrowing at
the right C5-6 foramen due to bony osteophytic changes.
Id. Her July 2013 cervical MRI showed mild to
moderate degenerative changes centered at ¶ 5-6 and mild
to moderate right neuroforaminal narrowing. Id.
physical examination of Plaintiff's cervical spine, Dr.
Clavet indicated Plaintiff experienced moderate tenderness at
the base of the neck extending to the left upper trapezius
and achieved chin-to-chest with good extension and full
lateral rotation without significant discomfort. Tr. at 534.
Regarding Plaintiff's lumbar spine, Dr. Clavet noted
palpation of the thoracolumbar and lumbosacral spine was
unremarkable; Plaintiff experienced a little bit of
discomfort with flexion and extension; flexion to 60 degrees
and extension to 10 degrees beyond neutral. Id. In
addition, Dr. Clavet noted Plaintiff's right hip ranged
well without pain and FABER (flexion, abduction, and external
rotation) testing was negative on the right. Id.
Clavet assessed cervical sprain/strain and lumbar
sprain/strain. Tr. at 535. He reported no acute traumatic
changes he would attribute to her March 2013 injury.
Id. Dr. Clavet agreed with Dr. Scott's treatment
plan and did not recommend any more aggressive neuraxial
December 17, 2013, Plaintiff was seen by Dr. Hopla. Tr. at
492. Dr. Hopla noted Plaintiff's head MRI was normal and
Plaintiff should probably see a neurologist about her
January 21, 2014, Plaintiff followed up with Dr. Scott. Tr.
at 531- 32. Plaintiff reported her neck and back were feeling
a little bit better, but had persistent radiating pain in her
right leg and hip. Tr. at 531. Dr. Scott performed a physical
examination and found negative straight leg raise
bilaterally, good functional knee flexion-extension and hip
flexion bilaterally, mild to modest discomfort with internal
and external rotation of the right hip, and intact sensation
to light touch and pressure in her upper and lower
extremities. Id. After examining Plaintiff on
multiple occasions, Dr. Scott could not identify any
impressive substantial pathology and said he did not have
anything else to offer her for her neck and back.
Id. Dr. Scott noted he offered Plaintiff a
therapeutic intra-articular hip injection, which she
declined, and offered a referral to a surgical hip specialist
for another opinion. Id. Dr. Scott stated he felt
Plaintiff's neck and back should not keep her from
working and that she could work without restrictions. Tr. at
January 24, 2014, Plaintiff followed up with Dr. Sandoz about
her head injury. Tr. at 546-48. Plaintiff described her
symptoms as incapacitating. Tr. at 546. She indicated the
pain was aggravated by sitting up and sound and associated
symptoms included clumsiness, gait disturbance, headache,
irritability, and visual disturbance. Id. Dr. Sandoz
also noted her associated tinnitus and back pain and that she
was taking medication on a daily basis to control her
headache and pain. Id. Dr. Sandoz indicated
Plaintiff had muscle spasm in her cervical and lumbar spine,
experienced mild pain with motion in her cervical spine, and
experienced moderate pain with motion in her lumbar spine.
Tr. at 547. He assessed posttrauma headache, lumbar disc
displacement, other and unspecified disc disorder of cervical
radiculopathy, and dizziness. Id. He prescribed
Imitrex, Tramadol, and Elavil for her pain and noted she
needed to take the Tramadol on a daily. Id. Dr.
Sandoz stated Plaintiff had achieved maximum medical
improvement for her headache and lumbar and cervical disc
disease. Id. He said one other option for her
headache might be Botox and indicated she needed a functional
capacity evaluation (“FCE”). He noted awaiting a
neuropsychological exam. Id.
February 17, 2014, Tracy Hill (“Ms. Hill”), a
physical therapist at Columbia Rehabilitation Clinic,
performed an FCE. Tr. at 573-594. Plaintiff reported an
initial pain level of 5/10. Tr. at 573. Her highest pain
level during the exam was an 8/10 with lifting. Id.
Ms. Hill found Plaintiff could meet the demands of limited
sedentary to limited light work. Id. Plaintiff
tolerated occasional walking, stairclimbing, kneeling,
bending, and reaching. Id. She did not tolerate
occasional squatting or twisting. Id. Plaintiff
could lift 9 to 14 pounds at various heights on an occasional
basis, carry 13 pounds with two hands; carry 9 pounds in each
hand, and push and pull 10 pounds loaded in a sled.
Id. Plaintiff reported a sitting tolerance of 45
minutes, a standing tolerance of at least 15 minutes, and a
standing/walking tolerance of at least 30 minutes.
Id. Ms. Hill observed Plaintiff to sit for a maximal
time of 15 minutes, stand for a maximal time of 13 minutes,
and stand/walk for a maximal time of 17 minutes. Id.
Plaintiff's cervical and lumbar ROM were limited.
Id. The results of Plaintiff's treadmill test
placed her in the fair classification of aerobic capacity and
her functional aerobic capacity qualified her for light work.
Id. Ms. Hill noted Plaintiff put forth a consistent
effort during the evaluation and she had taken one Ultram two
hours prior to testing and took an Ultram one hour and 40
minutes into testing. Id.
9, 2014, Plaintiff underwent a neuropsychological evaluation,
performed by Dr. Nicholas Lind (“Dr. Lind”). Tr.
at 596-615. Plaintiff reported experiencing headaches since
her March 2013 injury with an intensity of 8/10 without
medication and 3/10 with medication. Tr. at 608. She also
reported decreased sleep, ability to engage in previously
enjoyed activities, energy, and concentration, but denied
feelings of guilt or changes in appetite, irritability, or
sex drive. Tr. at 609. Plaintiff acknowledged apprehension
about returning to work, but denied any PTSD symptoms.
Id. She noted a change in her speech pattern after
her injury and reported forgetfulness and eye fatigue when
reading. Id. Plaintiff reported injuring her neck
and lower back in an automobile accident approximately 30
years prior to the evaluation, but denied any dizziness,
headaches, or difficulty thinking associated with it or any
other accident. Id. She stated she was diagnosed
with high blood pressure three or four ...