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
the Honorable Terry L. Wooten, United States District Judge,
dated February 23, 2018, referring this matter for
disposition. [ECF No. 10]. 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. 9].
filed 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 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 court reverses and remands the
Commissioner's decision for further proceedings as set
March 25, 2014, Plaintiff filed applications for DIB and SSI
in which she alleged her disability began on February 8,
2009. Tr. at 194-204. Her applications were denied initially
and upon reconsideration. Tr. at 108- 12, 114-19. On February
28, 2017, Plaintiff had a hearing before Administrative Law
Judge (“ALJ”) Brian Garves. Tr. at 32-66
(Hr'g Tr.). The ALJ issued an unfavorable decision on
April 11, 2017, finding Plaintiff was not disabled within the
meaning of the Act. Tr. at 15-31. 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 1-6. Thereafter,
Plaintiff brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on February
6, 2018. [ECF No. 1].
Plaintiff's Background and Medical History
Plaintiff was 44 years old at the time of the hearing. Tr. at
60. She completed high school. Id. Her past relevant
work (“PRW”) was as a machine operator, machine
cleaner, and deburrer. Tr. at 40-44. She alleges she has been
unable to work since February 28, 2009. Tr. at 194.
presented to the emergency room (“ER”) at
Regional Medical Center (“RMC”) on April 18,
2012, with complaints of flu-like symptoms. Tr. at 398.
Plaintiff also indicated she had been unable to obtain her
diabetes medication. Id. The attending physician
diagnosed bronchitis and discharged Plaintiff with
prescriptions for Azithromycin, Tessalon Perles, and
Metformin. Tr. at 401.
presented to the ER at RMC on August 16, 2012, with
complaints of intermittent left flank pain and elevated blood
glucose levels due to an inability to refill medication. Tr.
at 371. The attending physician diagnosed uncontrolled
non-insulin dependent diabetes, hyperglycemia, and myalgia of
left flank area, and he discharged Plaintiff with
prescriptions for Glucophage and potassium chloride. Tr. at
presented to Alan Huellmantel, M.D. (“Dr.
Huellmantel”), on May 22, 2013, complaining of right
knee pain, chest pain, and intermittent left-hand tingling
and numbness. Tr. 424. Dr. Huellmantel diagnosed
hypersecretory gastropathy, diabetes mellitus, and localized
primary osteoarthritis of the right knee. Id.
reported right knee pain and swelling to James P. Marro, M.D.
(“Dr. Marro”) on May 29, 2013. Tr. at 317-18. He
noted good range of motion (“ROM”) with mild
effusion and exquisite tenderness over the medial joint line.
Id. He assessed arthritis and explained
Plaintiff's obesity was a significant factor. Tr. at 319.
He noted Plaintiff was not a candidate for steroid injections
due to her uncontrolled blood glucose levels, but stated he
would re-evaluate once Plaintiff's diabetes was better
followed up with Dr. Marro on September 18, 2013, reporting
her right knee was still painful and her blood glucose levels
were not controlled. Tr. at 320. Dr. Marro assessed
degenerative joint disease and prescribed Daypro. Tr. at 321.
returned to Dr. Marro on February 25, 2014, with complaints
of continued right knee pain. Tr. at 322. She noted Daypro
provided some relief, but did not last all day. Id.
Dr. Marro observed pain and crepitus with ROM, mild effusion,
and significant tenderness over the medial joint line.
Id. Dr. Marro assessed arthritis and noted Plaintiff
had symptoms of peripheral neuropathy needing further
agency medical consultant Jean Smolka, M.D. (“Dr.
Smolka”), reviewed the record on September 26, 2014,
and determined the evidence was insufficient to determine the
severity of Plaintiff's impairments. Tr. at 79. Dr.
Smolka determined Plaintiff was not disabled. Tr. at 81.
presented to Kevin L. Ray, DPM (“Dr. Ray), on October
1, 2014, with complaints of heel pain. Tr. at 435. Dr. Ray
observed pain on palpation on the plantar medial calcaneal
tuber of the left heel. Id. X-rays and ultrasound
indicated calcaneal spur and inflammation at the insertion of
the plantar fascia. Id. He assessed plantar
fasciitis, diabetes, and calcaneal spur, and administered
injection therapy with Lidocaine, Marcaine, and
presented to Stephen Keen, PA-C (“Mr. Keen”), on
October 14, 2014, with complaints of poorly-controlled
diabetes and intermittent right knee pain, stable with
over-the-counter NSAIDS. Tr. at 446. Mr. Keen assessed
non-complicated, uncontrolled diabetes mellitus and
unspecified osteoarthrosis. Tr. at 447.
followed up with Dr. Ray on October 22, 2014, with complaints
of heel pain. Tr. at 434. She reported she still had
discomfort. Id. An ultrasound indicated inflammation
at the insertion of the plantar fascia. Id. Dr. Ray
assessed plantar fasciitis and calcaneal spur and discussed
treatment options. Id.
was examined by Monnieque Singleton, M.D. (“Dr.
Singleton”), on October 28, 2014, for a follow-up on
diabetes mellitus and Plaintiff's report of pain in her
finger tips and toes. Tr. at 443. Dr. Singleton assessed
uncontrolled diabetes mellitus and polyneuropathy, refilled
Metformin, and prescribed Levemir, Glimepiride, and
Neurontin. Tr. at 444.
followed up with Dr. Ray for complaints of heel pain. Tr. at
459. On November 19, 2014, Dr. Ray discussed treatment
options and prescribed Medrol and a night splint.
Id. On December 11, 2014, Plaintiff reported the
night splint provided some relief, but she continued to have
discomfort. Tr. at 460. Dr. Ray administered injections.
Id. On January 8, 2015, Plaintiff reported the
injections were not helpful and she was still experiencing
pain. Tr. at 461. Dr. Ray and Plaintiff discussed surgical
and non-surgical options, and he advised Plaintiff to
continue stretching. Id.
second state agency medical consultant, George Walker, M.D.
(“Dr. Walker”), reviewed the record on January 9,
2015. He determined Plaintiff's medical conditions did
not result in significant limitations in her ability to
perform basic work activities and were not severe enough to
be considered disabling. Tr. at 104-105.
January 12, 2015, Plaintiff presented to Margaret Beth
Grossman, D.O. (“Dr. Grossman”), seeking medical
clearance for left foot surgery. Tr. at 493. Dr. Grossman
noted an abnormal electrocardiogram (“ECG”) and
referred Plaintiff for additional cardiac evaluation. Tr. at
494. Plaintiff followed up with Lauren Murphy, P.A.
(“Ms. Murphy”), on January 30, 2015. Tr. at 490.
Ms. Murphy noted Plaintiff's repeat ECG was normal and
cleared her for surgery. Tr. at 490-91.
February 2, 2015, Plaintiff presented to RMC for surgical
consultation. Tr. at 568. The attending physician cleared
Plaintiff for surgery and adjusted Plaintiff's medication
to address her uncontrolled diabetes. Id. Plaintiff
followed up with Dr. Ray on February 4, 2015. Tr. at 460.
Plaintiff reported she was ready for surgical correction and,
after reviewing Plaintiff's medical records, Dr. Ray
scheduled surgery. Id.
February 6, 2015, Plaintiff was admitted to RMC for an
endoscopic plantar fasciotomy and calcaneal ostectomy
performed by Dr. Ray. Tr. at 506. Plaintiff was discharged
with no complications. Id.
March 25, 2015, Plaintiff reported to Advanced Diagnostic
Imaging Center for imaging of both knees. Tr. at 454. Leland
D. Cropper Jr., M.D. (“Dr. Cropper”), indicated
imaging of left knee was normal and imaging of right knee
revealed mild osteoarthritis in the medial compartment. Tr.
April 2, 2015, Plaintiff returned to Dr. Ray. Tr. at 464.
Plaintiff reported burning in the bottom of her feet that she
attributed to elevated blood glucose levels. Id. Dr.
Ray assessed neuritis and prescribed topical creams.
April 30, 2015, Plaintiff presented to Dr. Ray with
complaints of heel pain. Tr. at 465. Plaintiff reported she
was doing better, but continued to experience mild
discomfort. Id. Dr. Ray noted an ultrasound
indicated minimal inflammation of the left heel. Id.
He discussed with Plaintiff her post-operative course and
advised her to continue stretching and icing. Id.
8, 2015, Plaintiff presented to Dr. Marro. Tr. at 607. She
reported right knee pain and intermittent swelling with
ambulating and bending. Id. Plaintiff indicated
ibuprofen provided limited relief and requested an injection.
Tr. at 607, 610. Dr. Marro assessed mild crepitus to range of
motion, mild to moderate effusion, and generalized tenderness
with palpitation over the medial joint line. Tr. at 609. Dr.
Marro discussed risks associated with injection, and
Plaintiff indicated a desire to proceed. Tr. at 610. Dr.
Marro injected one cc of Triamcinolone, two cc of Lidocaine,
and two cc of Marcaine into Plaintiff's right knee.
October 21, 2015, Plaintiff followed up with Ms. Murphy
regarding her diabetes mellitus and medication refills. Tr.
at 485. Plaintiff reported fluid accumulation in her legs.
Tr. at 485-86. Ms. Murphy assessed type 2 diabetes with
hyperglycemia and mixed hyperlipidemia. Tr. at 486. On
November 11, 2015, Plaintiff presented to Ms. Murphy, who
referred her to a healthy living center for her morbid
obesity, uncontrolled diabetes mellitus, and hyperlipidemia.
Tr. at 482-83.
November 24, 2015, Plaintiff presented to Dr. Marro
complaining of right knee pain. Tr. at 614. Plaintiff
reported she had a few months' relief from injections,
but her pain had returned. Id. Dr. Marro observed
mild effusion, tenderness to palpation over the medial joint
line, and discomfort with range of motion. Tr. at ...