United States District Court, N.D. Oklahoma
CONNIE S. W., Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
F. JAYNE, MAGISTRATE JUDGE.
matter is before the undersigned United States Magistrate
Judge for a report and recommendation. Plaintiff Connie S. W.
seeks judicial review of the Commissioner of the Social
Security Administration's decision finding that she is
not disabled. For the reasons explained below, the
undersigned RECOMMENDS that the
Commissioner's decision denying benefits be
General Legal Standards and Standard of Review
claimant for disability benefits bears the burden of proving
a disability. 42 U.S.C. § 423(d)(5); 20 C.F.R.
§§ 404.1512(a), 416.912(a). “Disabled”
is defined under the Social Security Act as an
“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 12 months.” 42 U.S.C. §
423(d)(1)(A). To meet this burden, a plaintiff must provide
medical evidence demonstrating an impairment and the severity
of that impairment during the time of his alleged disability.
20 C.F.R. §§ 404.1512(b), 416.912(b). A disability
is a physical or mental impairment “that results from
anatomical, physiological, or psychological abnormalities
which are demonstrable by medically acceptable clinical and
laboratory diagnostic techniques.” 42 U.S.C. §
423(d)(3). A medically determinable impairment must be
established by “objective medical evidence, ”
such as medical signs and laboratory findings, from an
“acceptable medical source, ” such as a licensed
and certified psychologist or licensed physician; the
plaintiff's own “statement of symptoms, a
diagnosis, or a medical opinion is not sufficient to
establish the existence of an impairment(s).” 20 C.F.R.
§§ 404.1521, 416.921. See 20 C.F.R.
§§ 404.1502(a), 404.1513(a), 416.902(a),
416.913(a). A plaintiff is disabled under the Act only if his
“physical or mental impairment or impairments are of
such severity that he is not only unable to do his previous
work but cannot, considering his age, education, and work
experience, engage in any other kind of substantial gainful
work which exists in the national economy.” 42 U.S.C.
Security regulations implement a five-step sequential process
to evaluate a disability claim. 20 C.F.R. §§
404.1520, 416.920; Williams v. Bowen, 844 F.2d 748,
750-51 (10th Cir. 1988) (setting forth five steps in detail).
“If a determination can be made at any of the steps
that a plaintiff is or is not disabled, evaluation under a
subsequent step is not necessary.” Williams,
844 F.2d at 750. In reviewing a decision of the Commissioner,
the Court is limited to determining whether the Commissioner
has applied the correct legal standards and whether the
decision is supported by substantial evidence. See Grogan
v. Barnhart, 399 F.3d 1257, 1261 (10th Cir. 2005).
Substantial evidence is more than a scintilla but less than a
preponderance and is such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.
See Id. The Court's review is based on the
record, and the Court must “meticulously examine the
record as a whole, including anything that may undercut or
detract from the ALJ's findings in order to determine if
the substantiality test has been met.” Id. The
Court may neither re-weigh the evidence nor substitute its
judgment for that of the Commissioner. See Hackett v.
Barnhart, 395 F.3d 1168, 1172 (10th Cir. 2005). Even if
the Court might have reached a different conclusion, the
Commissioner's decision stands if it is supported by
substantial evidence. See White v. Barnhart, 287
F.3d 903, 908 (10th Cir. 2002).
Procedural History and the ALJ's Decision
then a 44-year-old female, applied for Title II disability
insurance benefits on December 2, 2014, alleging a disability
onset date of October 3, 2014. R. 14, 28. Plaintiff claimed
that she was unable to work due to anxiety and lower back
problems. R. 228. Plaintiff's claim for benefits was
denied initially on May 4, 2015, and on reconsideration on
June 29, 2015. R. 131-135, 139-141. Plaintiff then requested
a hearing before an ALJ, and the ALJ conducted the hearing on
February 23, 2017. R. 56. The ALJ issued a decision on May
17, 2017, denying benefits and finding Plaintiff not disabled
because she was able to perform other work that exists in
significant numbers in the national economy. R. 14-29. The
Appeals Council denied review, and Plaintiff appealed. R.
1-4; ECF No. 2.
found that Plaintiff had not engaged in substantial gainful
activity since her alleged onset date of October 3, 2014, and
that Plaintiff had the following severe impairments:
degenerative disc disease of the lumbar spine; degenerative
joint disease of both knees; right wrist pain due to prior
fracture; morbid obesity; generalized anxiety disorder; and
depressive disorder. R. 16. The ALJ also found Plaintiff had
non-severe impairments of high blood pressure; alleged
seizure disorder and/or syncope; and kidney stones. R. 17.
The ALJ identified a non-medically determinable impairment of
rule out panic disorder. Id. At step three, the ALJ
considered the severity of Plaintiff's disorders, singly
and in combination, and concluded that none was of such
severity to result in listing-level impairments. R. 18-20.
summarized the objective and opinion evidence in the
Right Wrist Impairment
record revealed that Plaintiff has a history of right wrist
pain due to prior fracture that did not heal correctly. At a
consultative examination performed by Kenneth Trinidad, D.O.,
in April 2014, Dr. Trinidad noted weakness in wrist and grip
strength and tenderness over the ulnar aspect and dorsum of
the wrist to palpation. R. 317. Dr. Trinidad opined that she
had a 20 percent impairment to the right hand as a result of
a non-union styloid fracture in the wrist, associated
stiffness and crepitance in the wrist, and weakness in right
wrist and grip strength. R. 318. The ALJ gave little weight
to Dr. Trinidad's opinions, because they covered
disability issues germane only to worker's compensation
matters. R. 24.
consultative examination performed by Abrar Adil, D.O., in
March 2015, Plaintiff stated her wrist pain was much improved
after several steroid injections, and she reported only
minimal 3/10 pain to the right dorsal wrist. R. 419. On
examination, Dr. Adil noted Plaintiff had no tenderness to
percussion over the right radial styloid, and her wrist and
finger ranges of motion were full bilaterally with minimal
signs of discomfort. R. 420, 424. Dr. Adil noted Plaintiff
could manipulate small objects and grasp tools. R. 424. MRI
of the right wrist in June 2015 showed a moderate amount of
soft tissue edema adjacent to the ulnar styloid, with a small
ununited ulnar styloid process fracture. R. 24, 537.
underwent repair surgery on her right wrist in September
2016. R. 23, 545. In January 2017, her wrist surgeon noted
she was slowly improving from surgery but still had swelling
on the ulnar side of the wrist. R. 547. Her surgeon allowed
her to work with a ten-pound weight restriction at that time.
Id. At a visit with her physical therapist in
January 2017, Plaintiff reported improvement in her right
wrist range of motion, strength, and mobility but noted
soreness along the ulnar wrist and into the ring and small
finger, which increased with activity. R. 501. She reported
she could make a fist but had difficulty gripping, and she
denied any numbness or tingling. Id. At a later
visit with the physical therapist in January 2017, Plaintiff
reported continued improvements in her right wrist strength,
range of motion, and mobility. R. 54. Plaintiff reported
infrequent sharp pains with multidirectional movements, but
she was able to perform more daily activities, such as light
lifting, without difficulty. Id. She reported that
gripping was improved, although she dropped things
occasionally, and her pain was 4/10 at the visit and 10/10 at
worst. Id. The therapist noted very mild swelling
over the ulnar wrist with mild, vague soreness over the ulnar
wrist and improved right wrist and elbow strength of 4
versus 3 at initial visit. R. 54-55.
February 8, 2017, Plaintiff's surgeon noted Plaintiff
still had pain on the ulnar side of the wrist, with pain into
the fourth and fifth metacarpals. R. 50. She could make a
full fist with full extension of all digits and full radial
and ulnar deviation and full pro/supination. Id. He
recommended a permanent 20-pound lifting restriction.
February 22, 2017, Plaintiff's primary care physician,
Curt Coggins, M.D., completed a physical RFC assessment of
Plaintiff. R. 318-535. Dr. Coggins opined that Plaintiff
could lift and carry up to 20 pounds occasionally and up to
five pounds frequently, and she had no limitations in use of
her hands for repetitive movements, including grasping. R.
532-533. He further opined that Plaintiff could continuously
handle and finger bilaterally. The ALJ gave little weight to
Dr. Coggins' opinions, finding that Dr. Coggins'
limitations appeared inconsistent and unsupported by the
medical evidence. R. 26-27. At the hearing held in February
2017, Plaintiff testified she still experienced pain,
weakness, and popping in her wrist. R. 77. However, Plaintiff
testified she could still use both hands for short periods.
regard to Plaintiff's complaints of pain, the ALJ noted
that physical examinations and imaging results revealed
modest findings. R. 22-26. In April 2014, Dr. Trinidad's
consultative examination revealed lumbar spine tenderness and
spasm, with negative straight-leg raising. R. 318. An MRI
scan of the lumbar spine performed in 2013 revealed mild
scoliosis of the thoracolumbar spine and mild to moderate
facet joint degenerative changes, along with an incidental
Tarlov cyst on the right at ¶ 1-S2. R. 302. In August
2015, Plaintiff underwent another MRI of the lumbar spine,
which revealed mild discogenic changes of the lumbar spine
and a sacral cyst at ¶ 1-S2, with no focal disc
abnormality, no significant central canal stenosis, and no
neural foraminal narrowing. R. 452. In November 2016,
Plaintiff obtained a third MRI of the lumbar spine, which
showed no significant abnormality, moderate degenerative disc
and facet joint changes, and a right S2 Tarlov cyst unchanged
from the previous study. R. 447. In September 2016, a nerve
conduction velocity study and EMG of the lower extremities
revealed normal examination results, despite Plaintiff's
complaints of back pain, numbness, and tingling of all
extremities. R. 461.
Adil's consultative examination in March 2015, Dr. Adil
observed Plaintiff moved about the exam room easily, had
relatively well-preserved spinal range of motion, negative
straight-leg raising bilaterally in seated and supine
position, normal toe and heel walking, and normal gait. R.
420. Dr. Adil ...