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White v. Commissioner of Social Security Administration

United States District Court, D. South Carolina

April 9, 2019

RONALD K. WHITE, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          REPORT AND RECOMMENDATION

          BRISTOW MARCHANT UNITED STATES MAGISTRATE JUDGE.

         The Plaintiff filed the complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner wherein he was denied disability benefits. This case was referred to the undersigned for a report and recommendation pursuant to Local Rule 73.02(B)(2)(a), (D.S.C.).

         Plaintiff applied for Disability Insurance Benefits (DIB) in October 2012, alleging disability beginning on June 17, 2012, due to injuries from a motorcycle accident; muscle spasms; fractured tibia, fibula in right ankle; and injuries to his hip, back, neck, and right shoulder. (R.pp. 18, 302, 392). Plaintiff's application was denied both initially and upon reconsideration. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ), which was held on October 17, 2014. (R.pp. 60-88). An ALJ thereafter denied Plaintiff's claim in a decision issued January 14, 2015. (R.pp. 118-126). Plaintiff appealed, and the Appeals Council remanded the case with instructions to obtain additional evidence regarding Plaintiff's impairments; to further evaluate his bilateral hand impairment at step two of the sequential evaluation process; to give further consideration to Plaintiff's maximum residual functional capacity (RFC) and provide an appropriate rationale with specific references to evidence of record in support of the assessed limitations; to further evaluate Plaintiff's alleged symptoms and provide rationale in accordance with the disability regulations pertaining to evaluation of symptoms and pertinent circuit case law; and, if warranted by the expanded record, to obtain supplemental evidence from a vocational expert (VE) to clarify the effect of the assessed limitations on Plaintiff's occupational base. (R.pp. 134-135).

         A second hearing was then held before the ALJ on August 26, 2016. (R.pp. 36-59). The ALJ thereafter again denied Plaintiff's claim in a decision issued December 2, 2016. (R.pp. 18-28). This time the Appeals Council denied Plaintiff's request for a review of the ALJ's decision, thereby making the December 2, 2016 determination of the ALJ the final decision of the Commissioner. (R.pp. 1-6). Plaintiff then filed this action in United States District Court, asserting that there is not substantial evidence to support the ALJ's decision, and that the decision should be reversed with an award of benefits or alternatively remanded for further consideration of his claim. The Commissioner contends that the decision to deny benefits is supported by substantial evidence, and that Plaintiff was properly found not to be disabled.

         Scope of review

         Under 42 U.S.C. § 405(g), the Court's scope of review is limited to (1) whether the Commissioner's decision is supported by substantial evidence, and (2) whether the ultimate conclusions reached by the Commissioner are legally correct under controlling law. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); Richardson v. Califano, 574 F.2d 802, 803 (4th Cir. 1978); Myers v. Califano, 611 F.2d 980, 982-983 (4th Cir. 1980). If the record contains substantial evidence to support the Commissioner's decision, it is the court's duty to affirm the decision. Substantial evidence has been defined as:

evidence which a reasoning mind would accept as sufficient to support a particular conclusion. It consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance. If there is evidence to justify refusal to direct a verdict were the case before a jury, then there is “substantial evidence.” [emphasis added].

Hays, 907 F.2d at 1456 (citing Laws v. Celebrezze, 368 F.2d 640 (4th Cir. 1966)); see also Hepp v. Astrue, 511 F.3d 798, 806 (8th Cir. 2008)[Nothing that the substantial evidence standard is even “less demanding than the preponderance of the evidence standard”].

         The Court lacks the authority to substitute its own judgment for that of the Commissioner. Laws, 368 F.2d at 642. “[T]he language of [405(g)] precludes a de novo judicial proceeding and requires that the court uphold the [Commissioner's] decision even should the court disagree with such decision as long as it is supported by substantial evidence.” Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).

         Medical Records [1]

         Plaintiff's medical records show that he was treated for injuries, including a right ankle fracture for which he underwent surgery (closed reduction performed by orthopedic surgeon Dr. Langdon Hartsock), at the Medical University of South Carolina (MUSC) after a motorcycle accident on June 17, 2012 (his alleged disability onset date). (R.pp. 610-616, 652-660). These medical records also indicate that Plaintiff had some injury to his right fingers. (R.p. 613).

         On August 7, 2012, Plaintiff had a follow up appointment as to his right ankle with Dr. Hartsock at MUSC Health. It was noted during this visit that Plaintiff complained of some triggering of his index finger, although it was not triggering that day. (R.p. 627). In October 2012, Dr. Hartsock's examination revealed that Plaintiff's right upper extremity showed positive Tinel's sign at the elbow, “[m]ildly positive one on the palmar side of wrist, and “subjective decreased sensation in the distribution of ulnar nerve.” (R.p. 661). Dr. Hartsock assessed Plaintiff with “[n]eck pain and right upper extremity numbness and tingling with possible cervical radiculopathy versus cubital tunnel syndrome and/or possible mild carpel tunnel syndrome.” Id.

         On October 11, 2012, Dr. John M. Ernst of Orthopaedic Specialists of Charleston/Roper St. Francis examined Plaintiff for complaints of right wrist pain and noted that Plaintiff had “[m]ild tenderness distal radius and ulna, radiocarpal, radioulnar ulnar carpal joints and dorsal carpus”, and that Plaintiff's thumb carpometacarpal (CMC) was tender with positive grind and crepitus. Dr. Ernst recommended a neurological consultation, thought Plaintiff might need to consider diagnostic wrist arthroscopy in the future, and noted that after cervical work-up Plaintiff might consider selective radiocarpal and CMC joint injections. (R.pp. 753-55). An electromyography/nerve conduction study on October 31, 2012 indicated:

[Plaintiff] has had pain in his neck. In the right upper extremity, he has some numbness and tingling in digits 3, 4 and 5. Occasionally, he has constant weakness at the shoulder and pain in the wrist. Exam shows some guarding of the right upper extremity, but decreased strength at the right shoulder compared with the left. There is some weakness at the finger flexors on the right compared with the left. There is decreased sensation in digits 3, 4 and 5 on the right dorsum of the hand.

(R.pp. 817-818). The results were normal in Plaintiff's arm, but an evaluation of Plaintiff's neck could not be made because Plaintiff was unable to relax. (R.pp. 817-818)

         On January 31, 2013, Plaintiff complained to Dr. Emily Darr at MUSC about radiating pain in the C6 and C7 distribution in his right arm with grip and wrist weakness. Dr. Darr noted “[g]rip and WE [wrist extensor] weakness on the right compared to left”, and recommended a right C6 selective nerve root block. (R.p. 669).

         On February 21, 2013, state agency physician Dr. Mary Lang reviewed Plaintiff's records and opined that Plaintiff could perform a range of light work[2] with limitations of frequent climbing of ramps/stairs and kneeling; occasional climbing of ladders/ropes/scaffolds, stooping, crouching, and crawling; and avoidance of concentrated exposure to hazards. Dr. Lang also opined that Plaintiff was limited to frequent pushing and pulling (including operation of hand and/or foot controls as to his right upper and lower extremities) and was limited to frequent reaching overhead, handling, and fingering on the right. (R.pp. 94-97).

         On April 1, 2013, Dr. Ernst assessed Plaintiff with joint and wrist pain and numbness and also found:

right thumb Eaton grade 2-3 [on a scale of 1 to 4] CMC joint osteoarthritis. Persistent right wrist ulnar carpal pain. Peripheral paresthesias appear to be more radicular rather than peripheral compressive neuropathy/awaiting nerve studies for review. [R]ecommend palmar-based opponens splint. We'll review[] nerve studies he received. Patient may ...

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