Opinion
Civil Action No. 2:16-cv-00844-RBH-MGB
07-17-2017
Sinclair Holmes, Jr., Plaintiff, v. Nancy A. Berryhill, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION OF MAGISTRATE JUDGE
This case is before the Court for a Report and Recommendation pursuant to Local 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 636(b)(1)(B).
A Report and Recommendation is being filed in this case, in which one or both parties declined to consent to disposition by the magistrate judge.
The Plaintiff, Sinclair Holmes, Jr., brought this action pursuant to Section 205(g) of the Social Security Act, as amended, (42 U.S.C. Section 405(g)), to obtain judicial review of a final decision of the Commissioner of Social Security Administration regarding his claim for disability insurance benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act.
RELEVANT FACTS AND ADMINISTRATIVE PROCEEDINGS
Plaintiff was 41 years old on his alleged disability onset date of August 24, 2009. (R. at 16, 26.) He alleged disability due to, inter alia, degenerative disc disease, degenerative joint disease, and high blood pressure. (See R. at 18, 120.) Plaintiff has a high school education and past relevant work as a painter. (R. at 26, 43.)
Plaintiff protectively filed an application for DIB on September 23, 2012 and an application for SSI on September 24, 2012. (R. at 16.) His applications were denied initially and on reconsideration. (R. at 16.) After a hearing before an Administrative Law Judge (ALJ) on July 29, 2014, the ALJ issued a decision on September 9, 2014, in which the ALJ found that Plaintiff was not disabled. (R. at 16-27.) The Appeals Council denied Plaintiff's request for review, (R. at 1-3), making the ALJ's decision the Commissioner's final decision for purposes of judicial review.
In 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 through December 31, 2015.
(2) The claimant has not engaged in substantial gainful activity since August 24, 2009, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq.).
(3) The claimant has the following severe impairments: degenerative disc disease, degenerative joint disease and status post hernia repair (20 CFR 404.1520(c) and 416.920(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 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
(5) After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform less than the full range of light work as defined in 20 CFR 404.1567(b) and 416.967(b). Specifically, the claimant can lift, carry, push and/or pull 20 pounds occasionally and 10 pounds frequently. He can sit for 6 hours in an 8-hour day, and stand and/or walk for 6 hours in an 8-hour day, with normal breaks. The claimant can only occasionally push and pull with the bilateral upper extremities. The claimant can never climb ladders, ropes or scaffolds, and he can only frequently balance. He can only occasionally climb ramps and stairs, stoop, kneel, crouch and crawl. Additionally, the claimant must avoid concentrated exposure to hazards.
(6) The claimant is unable to perform any past relevant work (20 CFR 404.1565 and 416.965).
(7) The claimant was born on July 13, 1968 and was 41 years old, which is defined as a younger individual age 18-49, on the alleged disability onset date (20 CFR 404.1563 and 416.963).
(8) The claimant has at least a high school education and is able to communicate in English (20 CFR 404.1564 and 416.964).
(9) Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is "not disabled," whether or not the claimant has transferrable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).(R. at 16-27.)
(10) Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569, 404.1569(a), 416.969, 416.969(a)).
(11) The claimant has not been under a disability, as defined in the Social Security Act, from August 24, 2009, through the date of this decision (20 CFR 404.1520(g) and 416.920(g)).
APPLICABLE LAW
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a "disability." 42 U.S.C. § 423(a). The Act also provides that supplemental security income (SSI) disability benefits shall be available for aged, blind, or disabled persons who have income and resources below a specific amount. See 42 U.S.C. § 1381 et seq. "Disability" is defined in the Act as the inability to "engage in 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" twelve months. See 42 U.S.C. § 423(d)(1)(A) (definition used in the DIB context); 42 U.S.C. § 1382c(a)(3)(A) (definition used in the SSI context).
"[T]he definition of disability is the same under both DIB and SSI . . . ." Mason v. Colvin, Civ. A. No. 9:12-1157-TLW-BM, 2013 WL 4042188, at *2 n.2 (citing Emberlin v. Astrue, Civ. A. No. 06-4136, 2008 WL 565185, at *1 n.3 (D.S.D. Feb. 29, 2008)).
To facilitate a uniform and efficient processing of disability claims, the 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 which equals an illness contained in the Administration's official Listing of Impairments found at 20 C.F.R. Part 404, Subpart P, Appendix 1, (4) has an impairment which prevents past relevant work, and (5) has an impairment which prevents him from doing substantial gainful employment. See 20 C.F.R. § 404.1520 (DIB context); 20 C.F.R. § 416.920 (SSI context). If an individual is found not disabled at any step, further inquiry is unnecessary. See 20 C.F.R. § 404.1520(a)(4) (DIB context); 20 C.F.R. § 416.920(a)(4) (SSI context); see also Hall v. Harris, 658 F.2d 260 (4th Cir. 1981).
A plaintiff is not disabled within the meaning of the Act if he can return to past relevant work as it is customarily performed in the economy or as the claimant actually performed the work. See SSR 82-62, 1982 WL 31386, at *3. The plaintiff bears the burden of establishing his inability to work within the meaning of the Act. 42 U.S.C. § 423(d)(5); 42 U.S.C. § 1382c(a)(3)(H)(I). He must make a prima facie showing of disability by showing that he is unable to return to his past relevant work. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983); see also Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).
Once an individual has established an inability to return to his past relevant work, the burden is on the Commissioner to come forward with evidence that the plaintiff can perform alternative work and that such work exists in the regional economy. See Grant, 699 F.2d at 191. The Commissioner may carry the burden of demonstrating the existence of jobs available in the national economy which the plaintiff can perform despite the existence of impairments which prevent the return to past relevant work by obtaining testimony from a vocational expert. See id. at 191-92.
The scope of judicial review by the federal courts in disability cases is narrowly tailored to determine whether the findings of the Commissioner "are supported by substantial evidence and whether the correct law was applied." Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); see also Richardson v. Perales, 402 U.S. 389 (1971); 42 U.S.C. § 405(g); 42 U.S.C. § 1383(c)(3). Consequently, the Act precludes a de novo review of the evidence and requires the court to uphold the Commissioner's decision as long as it is supported by substantial evidence. Pyles v. Bowen, 849 F.2d 846, 848 (4th Cir. 1988) (citing 42 U.S.C. § 405(g); Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)). The phrase "substantial evidence" is defined as:
such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. Substantial evidence consists of more than a mere scintilla of evidence but may be less than a preponderance.Smith v. Chater, 99 F.3d 635, 637-38 (4th Cir. 1996) (internal quotation marks and citations omitted).
Thus, it is the duty of this Court to give careful scrutiny to the whole record to assure that there is a sound foundation for the Commissioner's findings, and that her conclusion is rational. Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964). If there is substantial evidence to support the decision of the Commissioner, that decision must be affirmed. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
DISCUSSION
The Plaintiff contends that the Commissioner erred in failing to find him disabled. More specifically, Plaintiff contends the ALJ's decision is not supported by substantial evidence because the ALJ failed to "analyze[] all of the relevant evidence." (Dkt. No. 9 at 5.) Plaintiff further contends that "[s]ubstantial evidence does not support the ALJ's rejection of the evidence regarding [Plaintiff's] impairments," where Plaintiff's "complaints to all of his treating physicians are consistent throughout the medical records." (Dkt. No. 9 at 6.) Finally, Plaintiff asserts the ALJ "erred in finding that [Plaintiff] was not credible." (Dkt. No. 9 at 6.)
Plaintiff contends that the ALJ failed to analyze all of the relevant evidence; in his Brief, however, the only evidence to which Plaintiff points in complaining the ALJ failed to consider all the evidence is Plaintiff's work history. (See Dkt. No. 9 at 6.) The ALJ's failure to specifically indicate consideration of Plaintiff's work history is discussed below.
Plaintiff contends that "[s]ubstantial evidence does not support the ALJ's rejection of the evidence regarding [Plaintiff's] impairments," where Plaintiff's "complaints to all of his treating physicians are consistent throughout the medical records." (Dkt. No. 9 at 6.) Assuming Plaintiff's complaints to all of his treating physicians are consistent, this does not mean the ALJ was required to find Plaintiff disabled. See Craig v. Chater, 76 F.3d 585, 590 n.2 (4th Cir. 1996) ("Craig argues that the fact that Keller observed Craig (when she complained about the pain) transforms his observations into 'clinical evidence.' If this were true, it would completely vitiate any notion of objective clinical medical evidence. There is nothing objective about a doctor saying, without more, 'I observed my patient telling me she was in pain.'"). The ALJ thoroughly analyzed the medical evidence in the record, as will be discussed below in regards to Plaintiff's claim that the ALJ erred in analyzing Plaintiff's credibility.
As to the ALJ's assessment of Plaintiff's credibility, Plaintiff contends the ALJ "erred in ignoring [Plaintiff's] long and uninterrupted [22-year] work record." (Dkt. No. 9 at 6 of 7.) As stated in Craig v. Chater, 76 F.3d 585 (4th Cir. 1996), "the determination of whether a person is disabled by pain or other symptoms is a two-step process." Craig, 76 F.3d at 594. First, the plaintiff must present "objective medical evidence showing the existence of a medical impairment(s) which results from the anatomical, physiological, or psychological abnormalities and which could reasonably be expected to produce the pain or other symptoms alleged." Id. (internal quotation marks and citations omitted). The Fourth Circuit explained as follows:
It is only after a claimant has met her threshold obligation of showing by objective medical evidence a medical impairment reasonably likely to cause the pain claimed, that the intensity and persistence of the claimant's pain, and the extent to which it affects her ability to work, must be evaluated. See 20 C.F.R. §§ 416.929(c)(1) & 404.1529(c)(1). Under the regulations, this evaluation must take into account not only the claimant's statements about her pain, but also "all the available evidence," including the claimant's medical history, medical signs, and laboratory findings, see id.; any objective medical evidence of pain (such as evidence of reduced joint motion, muscle spasms, deteriorating tissues, redness, etc.), see 20 C.F.R. §§ 416.929(c)(2) & 404.1529(c)(2); and any other evidence relevant to the severity of the impairment, such as evidence of the claimant's daily activities, specific descriptions of the pain, and any medical treatment taken to alleviate it, see 20 C.F.R. §§ 416.929(c)(3) & 404.1529(c)(3).Craig, 76 F.3d at 595; see also SSR 96-7p, 1996 WL 374186, at *3 (listing factors "the adjudicator must consider in addition to the objective medical evidence when assessing the credibility of an individual's statements").
As explained by Magistrate Judge Hodges,
The Social Security Administration . . . published SSR 16-3p, 2016 WL 1119029 (2016), which supersedes SSR 96-7p, eliminates use of the term "credibility," and clarifies that subjective symptom evaluation is not an examination of an individual's character. Because the ALJ decided this case prior to March 16, 2016, the effective date of SSR 16-3p, the court analyzes the ALJ's decision based on the provisions of SSR 96-7p, which required assessment of the claimant's credibility. Although SSR 16-3p eliminates the assessment of credibility, it requires assessment of most of the same factors to be considered under SSR 96-7p.
In the case sub judice, the ALJ found "that the claimant's medically determinable impairments could reasonably be expected to cause some of the alleged symptoms." (R. at 25.) However, the ALJ found that "the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible for the reasons explained in this decision." (R. at 25.) The ALJ stated that she "considered the [Plaintiff's] subjective reports, as set forth at the hearing and in his Function Report," but that Plaintiff's "allegations regarding his limited abilities to walk, stand, sit, lift, bend, reach, kneel, climb and squat are not corroborated by the objective examinations of record (Exhibit 11E)." (R. at 24-25.) The ALJ noted Plaintiff's testimony at the hearing of July 29, 2014 as follows:
The claimant appeared at the hearing with a cane, which he testified his aunt gave to him. He stated he has not sought orthopedic treatment since May 2013. . . .(R. at 21.)
The claimant denied that he performs any household chores, and he stated he generally spends the majority of the day watching television. He testified he drives only short distances twice a week due to his back pain. He stated he lies down for approximately 6 hours throughout the day and walks to the mailbox but otherwise performs minimal activities of daily living. The claimant denied any medication side effects.
The claimant maintained he can walk only one block at a time, stand for only 15 minutes at a time, and sit for only 15 to 20 minutes at one time. He reported he can lift only 10 pounds. He stated he experiences back pain with no relief from epidural injections. The claimant also reported he experiences residual left leg radiculopathy, numbness and weakness since his knee surgery. He testified he has difficulty balancing and has used the cane his aunt gave him for approximately two years.
The ALJ first thoroughly analyzed Plaintiff's credibility as it pertains to his back pain, (see R. at 21-23), and then thoroughly analyzed Plaintiff's credibility as it pertains to his knee pain, (see R. at 23-25.) The ALJ also analyzed the opinion evidence, finding, inter alia, that the opinions of Dr. Moore and the state agency medical consultants were entitled to great weight. (R. at 25-26.) The ALJ stated, in summary,
[T]he above residual functional capacity assessment for a reduced range of light work is supported by the documentation of the claimant's degenerative disc disease, degenerative joint disease and status post hernia repair. The claimant's assertion that he requires a cane for ambulation is not supported by the medical record, as there is no evidence that he was ever prescribed a cane, and physical examinations generally reflect that he exhibited full strength of the extremities and ambulated without significant difficulty. Nonetheless, I have considered the evidence of his left radiculopathy in limiting the amount he can push and pull with the left lower extremity. Although his allegations regarding his limited ability to walk, stand, sit and lift are not corroborated by the objective examinations of record, I have considered the claimant's impairments and subjective pain symptoms in limiting the amount he can lift, carry, perform postural activities and be exposed to hazards. However, for the reasons set forth above, I cannot find the claimant's allegation that he is incapable of all work activity to be credible.(R. at 25-26.)
As noted above, Plaintiff contends the ALJ "erred in ignoring [Plaintiff's] long and uninterrupted [22-year] work record." (Dkt. No. 9 at 6 of 7.) There is certainly case law indicating that a plaintiff's long work history may support his or her credibility. See, e.g., Singletary v. Sec'y of Health, Ed. & Welfare, 623 F.2d 217, 219 (2d Cir. 1980) ("His prior work history justifies the inference that when he stopped working he did so for the reasons testified to."); see also 20 C.F.R. § 404.1529(c)(3) ("Because symptoms sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone, we will carefully consider any other information you may submit about your symptoms. . . . We will consider all of the evidence presented, including information about your prior work record. . . ."); 20 C.F.R. § 416.929(c)(3) (same).
However, the undersigned concludes that failure to mention a lengthy work history--standing alone--is not reversible error. In Nathans v. Colvin, Civ. A. No. 5:14-cv-03859-RBH, 2016 WL 403059 (D.S.C. Feb. 3, 2016), Judge Harwell declined to adopt the Magistrate Judge's Report and Recommendation recommending remand where the ALJ made no mention of Plaintiff's prior work record when assessing the Plaintiff's credibility. Judge Harwell stated,
The ALJ cited several reasons for discounting Plaintiff's credibility. The ALJ also noted Plaintiff's past relevant work at step four. The claimants in the cases relied on by the Magistrate Judge had significantly longer work histories than Plaintiff in this case. The Court declines to adopt an enhanced credibility doctrine that would require automatic remand any time an ALJ fails to discuss a claimant's good work record in determining credibility. To the extent the ALJ erred in failing to specifically discuss Plaintiff's work record in determining credibility, such error was harmless. Accordingly, the Court respectfully rejects the portion of the Report and Recommendation that recommends remand based on the ALJ's failure to mention or consider Plaintiff's prior work record when assessing Plaintiff's credibility.Nathans, 2016 WL 403059, at *5 (citations omitted); see also Anderson v. Colvin, Civ. A. No. 5:15-3110-JMC-KDW, 2016 WL 6684238, at *9 (D.S.C. Oct. 12, 2016), adopted at 2016 WL 6680034 (Nov. 14, 2016) ("While a long work history is commendable, in and of itself it does not undermine the ALJ's credibility assessment. [T]he ALJ's mere failure to mention [the claimant's] work history explicitly does not warrant remand or reversal in the face of his otherwise supported findings." (internal quotation marks and citation omitted); Maner v. Colvin, Civ. A. No. 1:12-2969-RBH, 2014 WL 4656383, at *5 (D.S.C. Sept. 17, 2014) ("[W]hile a long work history may be a factor supporting credibility, it is not controlling. . . . Here, the substantial evidence supports the findings by the ALJ regarding credibility. He cited numerous reasons for discounting the claimant's credibility."); Ramey v. Astrue, Civ. A. No. 4:11-2762-MGL, 2012 WL 6093797, at *5 (D.S.C. Dec. 7, 2012).
In the case sub judice, the ALJ thoroughly explained her credibility analysis, and that analysis is supported by substantial evidence. As to Plaintiff's complaints of knee pain, the ALJ noted that in September of 2010, Dr. Rittenberg "noted the claimant exhibited full range of motion of the bilateral knees and full strength of the lower extremities." (R. at 23; see also R. at 331.) As the ALJ indicates, Dr. Rittenberg did not document any gait abnormalities or the use of an assistive walking device. (See R. at 23; see also R. at 330-31.) In January of 2013, Plaintiff was seen at the Colleton County Medical Center complaining of lower extremity pain and swelling. (R. at 654.) The ALJ noted that although physical examination "revealed moderate tenderness and swelling with limited range of motion and joint effusion of the left knee," "an x-ray of the left knee was unremarkable, revealing no acute osseous abnormality." (R. at 23; see also R. at 654-56.) The "clinical impression" section of the records indicate Plaintiff had bursitis, and Plaintiff was prescribed Lortab and "provided a knee immobilizer and crutches." (R. at 23; see also R. at 655-56.)
The ALJ noted that Plaintiff underwent surgery in March of 2013 to remove the bursa in his left knee. (R. at 24; see also R. at 560-61.) As explained by the ALJ, the records indicate the surgery greatly improved Plaintiff's knee condition:
While the fact that the claimant underwent surgery certainly suggests his subjective reports of pain were credible, postoperative treatment notes reflect that the claimant ambulated with crutches in April 2013 but that the claimant reported improvement of his preoperative pain, describing his pain as only mild in severity. (Exhibit 26F). Additionally, in May 2013, the claimant reported his preoperative pain was "much" improved, and he again described his pain as only mild. The claimant reported some swelling over the left knee, but the examining physician noted the claimant exhibited normal sensation, no instability, no crepitus and normal range of motion. The physician stated the claimant's knee was healing well, and he did not document any gait abnormalities. Notably, the claimant reported he had returned to work as a painter at that time, indicating his knee mobility and pain had improved. (Exhibit 27F).(R. at 24.)
September 2013 treatment notes reflect that the claimant exhibited a positive left knee reflex with a painful straight leg raise and ambulated with discomfort. However, there is no mention that the claimant used an assistive walking device. Moreover, October 2013 treatment notes state that the claimant exhibited full strength of the bilateral lower extremities and that he ambulated without difficulty. (Exhibits 31F and 32F). A physical examination from April 2014 revealed atrophy of the left lower extremity but otherwise revealed full motor strength and normal sensation of the lower extremities with a normal gait and no mention of an assistive device. The medical record does not reflect any abnormalities of the left knee after April 2014. (Exhibit 35F). Accordingly, while I have considered the claimant's knee disorder in limiting the amount he can lift, carry, perform postural activities and be exposed to hazards, treatment notes and the claimant's own subjective reports indicate that his knee pain improved with surgery, and there are no objective findings since that time to suggest that his knee pain imposes greater limitations than those set forth above.
The ALJ also discussed the opinion evidence and stated that she gave "great weight" to Dr. Moore's opinion that Plaintiff was able to do "light duty work with no climbing" only a few weeks after Plaintiff's knee surgery. (R. at 25; see also R. at 569.) Additionally, the ALJ stated that "[g]reat weight ha[d] been given to the assessments of the state agency medical consultants, who found the [Plaintiff] could perform a reduced range of light work." (R. at 25.)
As to Plaintiff's back disorder, the ALJ noted that a June 2010 examination "revealed muscle spasms of the left posterior back but otherwise revealed full range of motion of the extremities and no gait abnormalities." (R. at 21; see also R. at 356-61.) The ALJ also noted the September 2010 report of consultative examiner Dr. Rittenberg. (R. at 21; see also R. at 330-31.) The ALJ stated,
[Dr. Rittenberg] noted the claimant reported back pain but got on and off the examination table without difficulty and was able to bend at the waist to 70 degrees. While he exhibited some decreased range of motion of the lumbar spine and tenderness of the lumbar paraspinous muscles, the claimant otherwise demonstrated full strength of the extremities, and Dr. Rittenberg did not document any gait abnormalities. (Exhibit 1F).(R. at 21; see also R. at 330-31.) The ALJ indicated an August 2010 MRI "revealed early disc desiccation at L4-5 and L5-S1 with moderate disc protrusion at L3-L4 to the right of the midline." (R. at 21; see also R. at 485.) Dr. Moesch's report-as noted by the ALJ--concludes that Plaintiff has "[m]oderate disc protrusion at L3-4 to the right of the midline which does not correlate with the patient's predominant left sided clinical symptoms." (R. at 485; see also R. at 21 (emphasis added).)
Dr. Boatwright's records from February of 2011 indicate that Plaintiff "continues to have left lower extremity radicular pattern of pain" but "no real weakness or giving way." (R. at 444; see also R. at 21-22.) The ALJ noted this record revealed "full strength (5/5) of the bilateral lower extremities" as well as a normal gait, "with only a mildly positive straight leg raise test." (R. at 21-22; see also R. at 444.) A March 2011 MRI "of the lumbar spine showed degenerative changes throughout the lumbar spine, most severe at L3-4 and L4-5," but the MRI "showed no evidence of nerve root impingement." (R. at 22; see also R. at 650.) As to L3-L4 and L4-L5, there was "[n]o significant change" from the prior exam. (R. at 650.)
As the ALJ notes, Plaintiff received a bilateral L4-5 transforaminal epidural steroid injection in March of 2011, but Plaintiff reported no significant relief from this injection. (R. at 22; see also R. at 449-52.) Because the injection did not provide relief, Dr. Boatwright referred Plaintiff to physical therapy. (R. at 451-52.) In June of 2011, Dr. Boatwright noted that Plaintiff had been in physical therapy for a few weeks and reported that "doing the exercise actually seems to make his back pain worse." (R. at 486.) Even so, as the ALJ noted, Dr. Boatwright's June of 2011 record indicates that Plaintiff's limp had generally resolved and that Plaintiff had "5/5 bilaterally symmetric strength." (R. at 486; see also R. at 22.)
Plaintiff's medical records from October of 2011 indicate that Plaintiff did have "a positive straight leg raise test on the right, lumbar spasms, moderately limited range of motion of the lumbar spine, and moderate soft tissue tenderness." (R. at 22; see also R. at 543-44, 661-64.) However, those same records indicate Plaintiff "exhibited a full range of motion of the extremities, with no sensation or motor deficits, and no gait abnormalities were documented." (R. at 22; see also R. at 544, 661-64.) As the ALJ noted, a November 2011 MRI "revealed a broad based disc protrusion at L3-4, which mildly deformed the exiting right L3 nerve root"; the MRI "also revealed degenerative disc disease at the L4-5 and L5-S1 but no evidence of nerve root impingement at those levels." (R. at 22; see also R. at 526.)
Records from November of 2011 indicate Plaintiff had "decreased sensation to light touch and pinprick over the left thigh," but motor strength in "both upper and lower extremities was 5/5." (R. at 22, 489.) The ALJ further stated as follows:
Notably, in November 2011, Curtis Worthington, M.D., noted that although the claimant complained of left leg pain and weakness, the claimant was unable to identify a specific muscle group that was particularly weak. Dr. Worthington also noted the claimant's MRI and lumbar myelogram revealed no clinical findings to correlate the claimant's reports of left lower extremity weakness. The claimant was administered an epidural block at that time, and although he reported only temporary relief from the block in January 2012, his physical examination revealed full strength (5/5) of the lower extremities, with full reflexes and the ability to heel and toe walk. Notably, upon review of a lumbar discogram, which revealed no new findings, Dr. Worthington noted that the claimant's radiological studies showed clinical abnormalities only on the right and that there was no clinical correlation of the claimant's subjective left lower extremity pain. Dr. Worthington stated surgery would likely not benefit the claimant. (Exhibit 18F).(R. at 22; see also R. at 516 ("[A]ll of [Plaintiff's] pain is on the left and all of his abnormalities are on the right. . . .").)
As noted by the ALJ, records from April of 2012 indicate Plaintiff had "limited mobility of the lumbar spine secondary to guarding." (R. at 23; see also R. at 538.) The ALJ stated, "While the claimant did exhibit some pain with straight leg raise testing and pain to palpation of the lumbar spine, the claimant exhibited intact sensation and no evidence of weakness with manual motor testing," and "no gait abnormalities were documented at that time." (R. at 23; see also R. at 537-38.) September 2012 records indicate Plaintiff's gait was normal. (R. at 23; see also R. at 541.)
The ALJ reviewed Plaintiff's September 2013 medical records, which indicate that Plaintiff "exhibited some mid-thoracic pain with slight edema to the left, and the physician noted the claimant exhibited pain with straight leg raise testing and ambulated with discomfort." (R. at 23; see also R. at 639.) A September 2013 MRI of the "thoracic spine revealed only mild degenerative disc disease within the upper thoracic spine, right greater than left, but no acute process." (R. at 23; see also R. at 652.) The ALJ further stated,
In April 2014, while he exhibited some tenderness over the paraspinal muscles and painful range of motion of the spine, the claimant ambulated with a normal gait and demonstrated no difficulty heel/toe walking. He also demonstrated full strength of the lower extremities with normal sensation. An EMG study from June 2014 did reveal evidence of mild left S1 radiculopathy. However, there are no corresponding strength deficits or weakness noted upon objective examination at that time. (Exhibit 35F). I have considered the evidence of the claimant's degenerative disc disease and mild left radiculopathy in limiting him to a reduced range of light work with only occasional pushing/pulling with the left lower extremity and with the postural limitations identified above. I have also considered the claimant's pain symptoms and any potential side effects from prescribed pain medications in finding the claimant must avoid concentrated exposure to hazards. However, there is no evidence that a cane was medically prescribed or medically necessary, and in light of the repeated notations that he ambulated with normal gait and demonstrated full strength of the bilateral lower extremities, the evidence indicates that the claimant retains the ability to perform the standing/walking demands of light work. While I have considered his back disorder in limiting the amount he can lift, carry, and perform postural activities, there are no objective findings showing this impairment imposes greater limitations than those set forth above.(R. at 23.)
After the ALJ's detailed analysis of the medical records, she also reviewed the opinion evidence. (See R. at 21-26.) Dr. Ward's opinion that Plaintiff should not work for two weeks was given "little weight" because, inter alia, "this opinion is only a temporary restriction based on the claimant's back pain exacerbation, and subsequent evidence shows the claimant generally exhibited full strength of the extremities and ambulated without any significant difficulty." (R. at 25.) The opinions of Dr. Moore and the state agency medical consultants were given great weight. (R. at 25.)
As noted above, the ALJ failed to mention Plaintiff's long work history in assessing Plaintiff's credibility. However, in light of the ALJ's thorough examination and analysis of Plaintiff's medical records and the opinion evidence, the undersigned concludes the ALJ's failure to mention the Plaintiff's work history does not warrant remand or reversal where the findings are otherwise supported by substantial evidence. See Reid v. Comm'r, 769 F.3d 861, 865 (4th Cir. 2014) ("While the Commissioner's decision must contain a statement of the case, in understandable language, setting forth a discussion of the evidence, and stating the Commissioner's determination and the reason or reasons upon which it is based, there is no rigid requirement that the ALJ specifically refer to every piece of evidence in his decision." (internal quotation marks and citations omitted)); see also supra pp. 8-9.) Here, Plaintiff's credibility analysis is supported by substantial evidence, even though the ALJ did not specifically mention Plaintiff's work history. The undersigned therefore recommends affirming the decision of the Commissioner. See Johnston v. Colvin, Civ. A. No. 9:13-cv-2098-BHH-BM, 2015 WL 893064, *3 (D.S.C. Mar. 3, 2015) ("Routinely, Courts have found harmless error where only one or a few reasons among many were improper, where the remaining bases constitute substantial evidence." (affirming Commissioner's decision and citing Mickles v. Shalala, 29 F.3d 918 (4th Cir. 1994)).
CONCLUSION AND RECOMMENDATION
Based on the foregoing, this Court concludes that the findings of the ALJ are supported by substantial evidence and recommends that the decision of the Commissioner be affirmed.
IT IS SO RECOMMENDED.
/s/_________
MARY GORDON BAKER
UNITED STATES MAGISTRATE JUDGE July 17, 2017
Charleston, South Carolina
Keefer v. Colvin, Civ. A. No. 1:15-4738-SVH, 2016 WL 5539516, at *11 (D.S.C. Sept. 30, 2016).