Opinion
Case No. CV 19-4629-JPR
08-26-2020
LETICIA T., Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
MEMORANDUM DECISION AND ORDER REVERSING COMMISSIONER
I. PROCEEDINGS
Plaintiff seeks review of the Commissioner's final decision denying her applications for disability insurance benefits ("DIB") and Social Security supplemental security income benefits ("SSI"). The parties consented to the jurisdiction of the undersigned under 28 U.S.C. § 636(c). The matter is before the Court on the parties' Joint Stipulation, filed March 10, 2020, which the Court has taken under submission without oral argument. For the reasons discussed below, the Commissioner's decision is reversed and this matter is remanded for further proceedings.
II. BACKGROUND
Plaintiff was born in 1968. (Administrative Record ("AR") 285.) She attended school in Mexico through third grade. (AR 70.) She worked as an assembler for an electronics company, a sewing-machine operator, a hand packager, and most recently a housekeeper. (AR 322, 341.) On March 9, 2015, she applied for benefits, alleging that she had been unable to work since March 15, 2009, because of "swelling," "[n]umbness," "[p]ain," "[t]ingling," and "[w]eakness" of the feet; fatigue; "[p]ain," "[s]welling," "tingling," and "[a]rthritis" of the knees; pain of the "[s]houlders and [c]ollar"; pain and "numbness" of the hips; and "[m]ental[] depress[ion]" from weight gain caused by "[p]hysical [i]nactivity." (AR 321; see AR 285.) After her applications were denied (AR 148-55, 159-64, 166-71), she requested a hearing before an Administrative Law Judge (AR 173). She appeared before the ALJ on July 20, 2017, but the hearing was continued so that she could obtain counsel. (AR 46-64.) A hearing was held on January 2, 2018, at which Plaintiff, represented by counsel, testified, as did a vocational expert. (AR 65-87.) In a written decision issued March 14, 2018, the ALJ determined that Plaintiff was not disabled. (AR 27-38.) On March 22, 2019, the Appeals Council denied her request for review. (AR 1-8.) This action followed.
Plaintiff's Disability Report states that she completed eighth grade (AR 322), but she testified at a hearing that she went through third grade in Mexico (AR 70).
III. STANDARD OF REVIEW
Under 42 U.S.C. § 405(g), a district court may review the Commissioner's decision to deny benefits. The ALJ's findings and decision should be upheld if they are free of legal error and supported by substantial evidence based on the record as a whole. See Richardson v. Perales, 402 U.S. 389, 401 (1971); Parra v. Astrue, 481 F.3d 742, 746 (9th Cir. 2007). Substantial evidence means such evidence as a reasonable person might accept as adequate to support a conclusion. Richardson, 402 U.S. at 401; Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007). It is "more than a mere scintilla, but less than a preponderance." Lingenfelter, 504 F.3d at 1035 (citing Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006)). "[W]hatever the meaning of 'substantial' in other contexts, the threshold for such evidentiary sufficiency is not high." Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). To determine whether substantial evidence supports a finding, the reviewing court "must review the administrative record as a whole, weighing both the evidence that supports and the evidence that detracts from the Commissioner's conclusion." Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). "If the evidence can reasonably support either affirming or reversing," the reviewing court "may not substitute its judgment" for the Commissioner's. Id. at 720-21.
IV. THE EVALUATION OF DISABILITY
People are "disabled" for purposes of receiving Social Security benefits if they are unable to engage in any substantial gainful activity owing to a physical or mental impairment that is expected to result in death or has lasted, or is expected to last, for a continuous period of at least 12 months. 42 U.S.C. § 423(d)(1)(A); Drouin v. Sullivan, 966 F.2d 1255, 1257 (9th Cir. 1992).
A. The Five-Step Evaluation Process
An ALJ follows a five-step sequential evaluation process to assess whether someone is disabled. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995) (as amended Apr. 9, 1996). In the first step, the Commissioner must determine whether the claimant is currently engaged in substantial gainful activity; if so, the claimant is not disabled and the claim must be denied. §§ 404.1520(a)(4)(i), 416.920(a)(4)(i).
If the claimant is not engaged in substantial gainful activity, the second step requires the Commissioner to determine whether the claimant has a "severe" impairment or combination of impairments significantly limiting her ability to do basic work activities; if not, a finding of not disabled is made and the claim must be denied. §§ 404.1520(a)(4)(ii) & (c), 416.920(a)(4)(ii) & (c).
If the claimant has a "severe" impairment or combination of impairments, the third step requires the Commissioner to determine whether the impairment or combination of impairments meets or equals an impairment in the Listing of Impairments ("Listing") set forth at 20 C.F.R., part 404, subpart P, appendix 1; if so, disability is conclusively presumed and benefits are awarded. §§ 404.1520(a)(4)(iii) & (d), 416.920(a)(4)(iii) & (d).
If the claimant's impairment or combination of impairments does not meet or equal one in the Listing, the fourth step requires the Commissioner to determine whether the claimant has sufficient residual functional capacity ("RFC") to perform her past work; if so, she is not disabled and the claim must be denied. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). The claimant has the burden of proving she is unable to perform past relevant work. Drouin, 966 F.2d at 1257. If the claimant meets that burden, a prima facie case of disability is established. Id.
RFC is what a claimant can do despite existing exertional and nonexertional limitations. §§ 404.1545(a)(1), 416.945(a)(1); see Cooper v. Sullivan, 880 F.2d 1152, 1155 n.5 (9th Cir. 1989). The Commissioner assesses the claimant's RFC between steps three and four. Laborin v. Berryhill, 867 F.3d 1151, 1153 (9th Cir. 2017) (citing § 416.920(a)(4)).
If that happens or if the claimant has no past relevant work, the Commissioner bears the burden of establishing that the claimant is not disabled because she can perform other substantial gainful work available in the national economy, the fifth and final step of the sequential analysis. §§ 404.1520(a)(4)(v), 404.1560(b), 416.920(a)(4)(v), 416.960(b).
B. The ALJ's Application of the Five-Step Process
At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since March 15, 2009, the alleged onset date. (AR 30.) Her date last insured was December 31, 2015. (Id.) At step two, she determined that Plaintiff had severe impairments of "osteoarthritis of the joints," "degenerative disc disease of the lumbar spine," "degenerative disc disease of the cervical spine," and "obesity." (Id.) She concluded that Plaintiff's plantar fasciitis was not severe because it did "not cause a significant limitation in [her] ability to perform basic work activities." (Id.)
At step three, she found that Plaintiff's impairments did not meet or equal any of the impairments in the Listing. (AR 32.) At step four, she determined that Plaintiff had the RFC to perform medium work except that she could "frequently climb ladders, ropes, and scaffolds, and balance and stoop," "occasionally climb ramps and stairs, and kneel, crouch, and crawl," and "frequently perform bilateral overhead reaching." (AR 33-34.) The ALJ found Plaintiff capable of performing her past relevant work as a hand packager and housekeeper. (AR 37-38.) Accordingly, she found her not disabled. (AR 38.) V. DISCUSSION
In Lucia v. SEC, 138 S. Ct. 2044, 2055 (2018), the Supreme Court held that ALJs of the Securities and Exchange Commission are "Officers of the United States" and thus subject to the Appointments Clause. To the extent Lucia applies to Social Security ALJs, Plaintiff has forfeited the issue by failing to raise it during her administrative proceedings. (See AR 10, 46-87, 158, 279-80); Meanel v. Apfel, 172 F.3d 1111, 1115 (9th Cir. 1999) (as amended); see also Kabani & Co. v. SEC, 733 F. App'x 918, 919 (9th Cir. 2018) (rejecting Lucia challenge because plaintiff did not raise it during administrative proceedings), cert. denied, 139 S. Ct. 2013 (2019).
Plaintiff alleges that the ALJ erred in determining her severe impairments, evaluating the opinion evidence, and assessing her symptom statements. (See J. Stip. at 3-12, 16-28, 30-35, 38-39.) Because the ALJ erred in the first and second respects, the matter must be remanded for further analysis and findings.
A. The ALJ Erred in Assessing Plaintiff's Alleged Foot Impairment
1. Dr. Mooney
a. Applicable law
"Acceptable medical sources" under the Social Security regulations include only licensed physicians, psychologists, optometrists, podiatrists, and speech pathologists. §§ 404.1513(a), 416.913(a). Chiropractors are treated as "other sources," see §§ 404.1513(d)(1), 416.913(d)(1); see also SSR 06-03p, 2006 WL 2329939, at *1 (Aug. 9, 2006), and an ALJ may reject opinions from an "other source" only by giving "reasons germane to each witness for doing so." Popa v. Berryhill, 872 F.3d 901, 906 (9th Cir. 2017) (as amended) (quoting Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012)). If an ALJ errs by rejecting an opinion from an "other source" without providing a germane reason, that error is harmless if the Court can "conclude from the record that the ALJ would have reached the same result absent the error." Molina, 674 F.3d at 1115; Marsh v. Colvin, 792 F.3d 1170, 1173 (9th Cir. 2015).
For claims filed on or after March 27, 2017, the rules in §§ 404.1502 and 416.902 (not §§ 404.1513 and 416.913) apply. Plaintiff's claims were filed before March 27, 2017, however, and thus the new regulations do not apply.
b. Relevant background
Plaintiff apparently suffered cumulative work-related impairment between May 2008 and March 2009, when she worked as a housekeeper at a hotel. (AR 341-42, 568.) Dr. Andrew Mooney, a chiropractor, evaluated and treated her as part of her worker's- compensation claim. (AR 773-831.) On July 7, 2016, Dr. Mooney completed a "Primary Treating Physician's Re-Evaluation Report and Request For Authorization." (AR 773-800.) He examined Plaintiff's shoulders, elbows, wrists, thoracic spine, lumbar spine, hips, knees, ankles, and feet. (AR 774-79.) He noted that she walked with a "slow, guarded gate [sic] pattern without a limp" and that she was "unable to heel-toe walk or perform a full squat due to a complaint of lumbar spine and bilateral foot pain." (AR 776.) The "Straight Leg Raise Supine" test, "Standing Kemp's Test," and "Patrick-Fabere's Test" were positive on both sides. (Id.) The ankle examination revealed a left hallux valgus and palpable tenderness of the bilateral calcaneus and plantar fascia. (AR 778.) Dr. Mooney reviewed MRIs of her lumbar spine, cervical spine, and feet as well as a study of her upper limbs. (AR 779.) He also reviewed records from the agreed medical examiners, a gasteroenterologist, and Plaintiff's treating podiatrist, Dr. Victoria Foley. (AR 780-90.) Based on his physical examination and review of her diagnostic studies and records, Dr. Mooney found "[c]ervical [s]pine [s]train/[s]prain with [m]yalgia" and "[d]isc [d]isplacement"; "[l]eft [u]lnar [n]europathy"; bilateral carpal tunnel syndrome; "[l]umbar [s]pine [s]train/[s]prain with [m]yalgia," "[d]isc [d]isplacement," and "[r]adiculitis"; bilateral plantar fasciitis; "[r]ule [o]ut" "[c]alcaneal [s]pur" on both feet; "[l]eft [h]allux [v]algus"; and "reported" depression and anxiety, sleep disturbance, gastritis, and "[s]exual [d]ysfunction." (AR 790.) He opined that she was temporarily totally disabled ("TTD") from July 7 through August 21, 2016, and had not "reached [m]axim[um m]edical [i]mprovement" ("MMI"). (AR 792.) He examined her again on August 11, 2016, noting the same diagnoses as those in his July report. (AR 821.) He opined that she had not reached MMI and that she was TTD from August 11 through September 25, 2016. (AR 823.)
A straight-leg-raise test involves mechanical manipulation of the legs, stressing the neurological tissues in the spine; specific symptoms reported at different degrees of flexion can indicate nerve compression. See The Pain Clinic Manual 44-45 (Stephen E. Abram & J. David Haddox eds., 2d ed. 2000).
The Kemp test assesses the lumbar-spine facet joints to detect pain. See Kemp test, Physiopedia, https://www.physio-pedia.com/KEMP_test (last visited Aug. 25, 2020).
The Patrick, or Fabere, test measures pain or dysfunction in the hip and sacroiliac joints. Patrick Test, The Free Dictionary, http://medical-dictionary.thefreedictionary.com/Patrick+test (last visited Aug. 25, 2020).
Hallux valgus is a condition in which the big toe is bent toward the midline of the foot so that it overlaps the second toe. See Medical Definition of Hallux Valgus, MedicineNet, https://www.medicinenet.com/script/main/art.asp?articlekey=6406 (last visited Aug. 25, 2020). It may be accompanied by a bunion and is frequently associated with inflammation. Id. It can be related to inflammation of the nearby bursa or degenerative joint disease. Id.
c. Analysis
The ALJ summarized some of Plaintiff's treatment records and the opinion of internist Dr. Seung Ha Lim, the consultative examiner. (AR 34-35.) Dr. Lim opined that Plaintiff was restricted to
standing and/or walking about 6 hours in an eight-hour workday with appropriate breaks. [She can] sit for 6 hours in an eight-hour day with appropriate breaks. [She can] lift and/or carry 50 pounds occasionally and 25
pounds frequently. Pushing, pulling, and overhead reaching is unlimited other than as shown for lifting and/or carrying. [She] has no other impairment related physical limitations.(AR 726.) The ALJ gave "great weight" to Dr. Lim's opinion, finding that it was "consistent with the record as a whole." (AR 34.)
To reject Dr. Mooney's opinion, the ALJ had to give only a germane reason; she failed to do so because she failed to address the opinion at all. A chiropractor is not an acceptable medical source. See §§ 404.1513(d)(1), 416.913(d)(1); see also SSR 06-03p, 2006 WL 2329939, at *2. That is not a sufficient reason, however, to reject his opinion. See Haagenson v. Colvin, 656 F. App'x 800, 802 (9th Cir. 2016) (finding that ALJ failed to provide germane reason for rejecting opinion of claimant's nurse and counselor because "[t]he only reason that the ALJ offered for rejecting their opinions is that they are not 'acceptable medical sources' within the meaning of the federal regulation").
And although inconsistency with other objective evidence can be a germane reason to reject other-source evidence, see Molina, 674 F.3d at 1111-12, and Dr. Lim's opinion was generally at odds with Dr. Mooney's assessment, the ALJ did not cite that inconsistency as a reason for ignoring or rejecting Dr. Mooney's opinion. Indeed, the ALJ did not cite any specific inconsistencies between the two doctors' opinions or between Dr. Mooney's opinion and any other medical-opinion evidence. See Nguyen v. Berryhill, No. 3:16-cv-01665-LB, 2017 WL 1196800, at *15 (N.D. Cal. Mar. 31, 2017) (finding ALJ's reason for rejecting other-source opinion "insufficient" because ALJ failed to "cite specific inconsistencies" with objective evidence); see also Bruce v. Astrue, 557 F.3d 1113, 1115 (9th Cir. 2009) (reasons for rejecting other-source testimony must be "germane" and "specific" (citation omitted)).
Moreover, the error was not harmless. Dr. Mooney found that Plaintiff had a "slow, guarded gate [sic] pattern" and was "unable to heel-toe walk or perform a full squat." (AR 776, 807.) He concluded that she was TTD for more than two months, until he stopped treating her. (AR 792, 823.) The ALJ specifically found that Plaintiff "consistently showed no restrictions in ambulation" and that "nothing in the record show[ed] that [her] plantar fasciitis . . . ha[d] any effect on her functioning" (AR 30), apparently ignoring Dr. Mooney's diagnoses (see AR 790, 821). Further, Dr. Mooney's opinion was consistent with that of Dr. Foley, discussed more fully below. The two jobs the ALJ found Plaintiff could perform, hand packager and housekeeper, are both medium exertional work, which requires "standing or walking, off and on, for a total of approximately 6 hours in an 8-hour workday." SSR 83-10, 1983 WL 31251, at *6 (Jan. 1, 1983). Thus, the Court cannot "conclude from the record that the ALJ would have reached the same result absent the error." Molina, 674 F.3d at 1115.
Housekeeper is light work as generally performed, but the VE testified that it was medium work as Plaintiff performed it. (AR 84.) Even when performed as light work, the DOT description of its duties demonstrates that it involves a good deal of walking or standing. See Cleaner, Housekeeping, DOT 323.687-014, 1991 WL 672783 (Jan. 1, 2016).
Because the ALJ failed to assign any particular weight to Dr. Mooney's opinion or provide a germane reason for rejecting it, remand is warranted.
2. Dr. Foley
a. Applicable law
In evaluating doctors' opinions, an ALJ must state what weight she has given each opinion and explain why. See SSR 96-2p, 1996 WL 374188, at *5 (July 2, 1996); §§ 404.1527(e), 416.927(e). An ALJ errs when she "does not explicitly reject a medical opinion or set forth specific, legitimate reasons for crediting one medical opinion over another." Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014).
For claims filed on or after March 27, 2017, the rules in §§ 404.1520c and 416.920c (not §§ 404.1527 and 416.927) apply. See §§ 404.1520c, 416.920c (evaluating opinion evidence for claims filed on or after Mar. 27, 2017). Plaintiff's claims were filed before March 27, 2017, however, and thus the new regulations do not apply.
b. Relevant background
Dr. Foley treated Plaintiff as part of her worker's-compensation claim. (AR 540-72.) On February 9, 2011, she examined Plaintiff and completed a "Primary Treating Physician's Initial Report." (AR 568-74.) Plaintiff complained of "+9/10" "stabbing" "right heel" pain when "walking or standing" and "left foot" pain "in the bunion area." (AR 568.) Dr. Foley noted that she "ambulated with [a] limp," but she was able to "gait[] onto and off of the examination table without difficulty." (AR 570.) Her motor strength was "+5/5" "bilaterally to all muscles." (Id.) An ankle examination revealed "absolute tenderness with palpation, range of motion, dorsiflexion, plantar flexion, eversion, and inversion." (Id.) During a heel examination Plaintiff exhibited "severe pain with palpation of the calcaneus with lateral compression" and "pain with palpation of the insertion of the plantar fascia plantarly to the plantar medial turbercle of the calcaneus, right greater than left." (Id.) Dr. Foley noted that Plaintiff had an "abducted gait," a "short stride and an antalgic gait." (AR 571.) X-rays revealed a "large plantar calcaneal spur on the right," a "small calcaneal spur on the left," "a bunion deformity on the left first metatarsophalangeal joint," and "decreased joint space on the lateral aspect of the left first metatarsophalangeal joint." (Id.) She assessed "[c]alcaneal stress fracture on the right," "[p]lantar fasciitis bilaterally," and "[b]union on the left." (AR 572.) She recommended that Plaintiff get an MRI for the plantar fasciitis and calcaneal stress fracture. (Id.)
On April 4, 2011, Dr. Foley noted that the MRI report showed "moderately advanced" "reactive changes to the plantar fascia," "[e]dema in the plantar fat pad," "posterior tibialis peritendinitis, chronic tendinopathy, . . . mild intrasubstance partial tearing distally . . . without rupture," and "synovitis and arthritis of the first metatarsophalangeal joint on the right side." (AR 566.) She assessed "[p]lantar fasciitis, right side," "[p]ain," and "[d]ifficult walking." (AR 567.) She dispensed a "Cam walker" and "told [Plaintiff] to wear [it] at all times except when . . . taking a shower." (Id.) On April 25, 2011, Dr. Foley recommended that Plaintiff "get a fiberglass cast, so that she [would] be totally immobilized," and "[d]iscussed possible surgical intervention." (AR 564.) Plaintiff stated during a September 26, 2011, visit that she "previously . . . had taken Vicodin and . . . ha[d] been alternating between Vicodin and Motrin two to three times a week." (AR 561.) Dr. Foley again discussed a "fiberglass cast" and "cortisone injections." (AR 562.)
A CAM walker is a removable, inflatable cast. See Medical Boot, OrthoTape, http://orthotape.com/cam_walkers.asp (last visited Aug. 25, 2020).
Vicodin is an opioid pain reliever used to relieve moderate to severe pain. See Vicodin, WebMD, https://www.webmd.com/drugs/2/drug-3459/vicodin-oral/details (last visited Aug. 25, 2020).
On October 4, 2011, Dr. Foley gave Plaintiff a cortisone injection. (AR 560.) Plaintiff reported on November 8, 2011, that she was a "little bit better after the injection." (AR 557.) Dr. Foley gave her "a second cortisone injection." (AR 558.) On December 12, 2011, the "injection [had] helped a little bit." (AR 555.) Plaintiff was "wearing the Cam walker six hours daily" and was having "constant pain," but the "strong stabbing pain [was] less." (Id.)
Dr. Foley discussed with Plaintiff during a January 17, 2012 visit that she had "had the pain in the right foot for almost two years" and told her "that at this point [s]he would recommend foot surgery." (AR 554.) Plaintiff told Dr. Foley on March 20, 2012, that "she stands and walks approximately four hours total daily for 30 to 40 minutes at a time." (AR 550.) She rated her pain in the morning as "9/10" and "8/10" "after she warms up." (Id.) Plaintiff "refused surgery" and "the fiberglass cast." (Id.) Dr. Foley recommended that she get a pair of orthotics. (AR 551.) Further, she opined that Plaintiff had been TTD for more than a year but could "return to work as of March 20, 2012." (AR 552.) Plaintiff saw Dr. Foley for orthotic casting on April 30, 2012. (AR 546.) She assessed "[p]lantar fasciitis," "[c]apsulitis," "[b]ursitis," and "[a]bnormal gait." (Id.) She dispensed the orthotics on May 21, 2012. (AR 544.) Plaintiff reported on June 4, 2012, that her orthotics were "very comfortable but she d[id] not have any diminishing pain." (AR 542.) Dr. Foley again assessed an "[a]bnormal gait." (Id.) On July 2, 2012, Plaintiff reported that her pain was still "7/10," and Dr. Foley gave her a cortisone injection "into the right foot." (AR 540.) On July 31, 2012, she noted that Plaintiff had refused "to have surgery," "was walk[ing] . . . without any limp," "ha[d] reached her maximum medical benefit," and had "no permanent impairment." (AR 548-49.)
c. Analysis
The ALJ found that Plaintiff had "bilateral plantar fasciitis" that was not severe. (AR 30.) But she apparently based this finding at least in part on her inaccurate conclusions that Plaintiff "consistently showed no restrictions in ambulation" and "there is nothing in the record to show that the claimant's plantar fasciitis . . . ha[d] any effect on her functioning." (AR 30.) She did not assign any particular weight to Dr. Foley's opinions that Plaintiff had "difficult[y] walking," had an "abnormal gait," and was TTD from February 9, 2011, to March 20, 2012; indeed, she never discussed or even mentioned them. By failing to even mention a treating doctor's opinions, the ALJ erred. Garrison, 759 F.3d at 1012; see also Marsh, 792 F.3d at 1172-73 (finding error when ALJ gave no reason for not mentioning treating doctor or his notes); Jose Luis V.H. v. Saul, No. EDCV 18-2618-KS, 2020 WL 247315, at *4-5 (C.D. Cal. Jan. 16, 2020) (finding reversible error when ALJ failed to mention doctor's opinion or give opinion any weight).
The ALJ also incorrectly stated that Plaintiff "was never prescribed narcotic or other medications ordinarily used for severe pain and discomfort" and that "there is no evidence of [Plaintiff] receiving physical therapy [or] pain relief injections." (AR 36.) Plaintiff was prescribed narcotics, including Vicodin, Norco, and Tramadol. (See, e.g., AR 561, 641, 679.) Further, she underwent physical therapy and received cortisone injections. (See, e.g., AR 558, 560, 600.)
Moreover, the error was not harmless because the medium-work jobs identified by the ALJ that Plaintiff could perform require standing or walking, off and on, for a total of approximately six hours in an eight-hour workday. See SSR 83-10, 1983 WL 31251, at *6. Defendant argues that the error was harmless because Dr. Foley's opinions were all rendered before the period during which Plaintiff would have been eligible to actually receive benefits. (See J. Stip. at 14.) But in light of Dr. Mooney's (and Dr. Halperin's; see below) later similar statements, which the ALJ also ignored, Dr. Foley's opinions could have led to a reasonable inference that Plaintiff was afflicted with severe plantar fasciitis throughout the relevant period. Therefore, the Court cannot conclude from the current record that the ALJ would have reached the same result absent the error.
3. Dr. Halperin
a. Relevant background
Podiatrist Gabriel Halperin treated Plaintiff as part of her worker's-compensation claim. (AR 579-600.) On October 28, 2013, he examined her and completed a "Comprehensive Initial Podiatric Consultation" report. (AR 579-91.) He noted that she "walk[ed] without [a] limp" (AR 585), but she exhibited "pain on palpation over the rim of the heel with tingling neuritic pain" and had a "positive Tinel's sign at the common peroneal, deep peroneal, posterior tibial and medial calcaneal nerves" (AR 587-88). He diagnosed plantar fasciitis, "[c]alcaneal enthesopathy," "[c]hronic pain," "[p]eripheral nerve impairment," and "[n]euritis with heel pain of the sural nerve, posterior tibial nerve[,] and the lateral plantar nerve." (AR 588.) He recommended orthotics, "four steroid injections," a "[h]eel lift to reduce traction to the calcaneus," a "[n]ight splint," and pain medication. (AR 589.)
Tinel's sign is positive when tapping the affected nerve produces tingling. See Tinel's Sign, Healthline, https://www.healthline.com/health/tinels-sign#test (last visited Aug. 25, 2020).
Enthesopathy is inflammation of the site of attachment or insertion of ligaments, tendons, fascia, or articular capsule into bone and may be caused by chronic traction of the Achilles tendon on the calcaneus. See Achilles and plantar fascia enthesopathy, Radiopaedia, https://radiopaedia.org/cases/achilles-and-plantar-fascia-enthesopathy?lang=us (last visited Aug. 25, 2020). --------
Dr. Halperin stated in a March 3, 2014 progress report that Plaintiff's "[p]ain ha[d] increased," "[l]eft foot . . . greater than right," and that she was "complaining of knee pain." (AR 593.) She reported to him on April 14, 2014, that she had "not improved significantly." (AR 595.) He noted that he would delay "steroid injections until May." (Id.) On May 14, 2014, Plaintiff reported "improved pain with trigger injection[s] initially." (AR 596.) Dr. Halperin again noted "[p]ain on palpation" of Plaintiff's feet on May 28, July 9, and August 13, 2014. (AR 597-99.) After "[two] sessions [of physical therapy, Plaintiff] noted decreased pain." (AR 600.)
b. Analysis
Dr. Halperin diagnosed Plaintiff with plantar fasciitis and several other conditions. Other than noting Plaintiff's own subjective statements of symptoms, however, he did not document or provide any opinion regarding any functional limitations. But given that some of the ALJ's statements concerning the record clearly failed to take into account any of the treatment notes or opinions from the doctors who treated Plaintiff's feet (see supra sec. V.A.1.c & .2.c), her error in failing to discuss Dr. Halperin was not harmless. See Marsh, 792 F.3d at 1173 (ALJ's failure to discuss treating doctor's opinion was not harmless when ALJ did not mention doctor's statement that condition rendered plaintiff "pretty much nonfunctional").
B. Clinica de Salud Familiar
Plaintiff also argues that the ALJ "failed to provide proper discussion and consideration" of her treatment with Clinica de Salud Familiar. (J. Stip. at 23; see id. at 22.) The ALJ discussed these records. (See AR 35.)
As the ALJ noted, although the records documented Plaintiff's subjective complaints and treatment for shoulder and knee pain (AR 733-71, 841-57), they did not show any diagnostic test results or opinions suggesting that she had limitations greater than those in the RFC. (AR 35.) In any event, the ALJ can reconsider them on remand in light of the complete record.
C. Remaining Issues
Plaintiff asserts that the ALJ erred in evaluating her testimony and statements regarding her symptoms. (J. Stip. at 32-35, 38-39.) The ALJ should reevaluate Plaintiff's symptom testimony and statements once she has properly considered the treating doctors' opinions, so the Court does not address those arguments. See Negrette v. Astrue, No. EDCV 08-0737 RNB., 2009 WL 2208088, at *2 (C.D. Cal. July 21, 2009) (finding it unnecessary to address further disputed issues when court found that ALJ failed to properly consider treating doctor's opinion and lay-witness testimony).
VI. CONCLUSION
Consistent with the foregoing and under sentence four of 42 U.S.C. § 405(g), IT IS ORDERED that judgment be entered REVERSING the Commissioner's decision, GRANTING Plaintiff's request for remand, and REMANDING this action for further proceedings consistent with this Memorandum Decision. DATED: August 26, 2020
/s/_________
JEAN ROSENBLUTH
U.S. Magistrate Judge