On December 18, 2000, Ms. Curry sought treatment with orthopedic surgeon, Vincent DiStefano, M.D. She explained that she had been involved in a motor vehicle accident and since then had suffered from neck and shoulder pain. In addition, she expounded that her pain kept her from sleeping, that she could not raise her arm above her head, and had difficulty reaching. On physical examination, Dr. DiStefano found slight decreased range of motion in her neck; that she had tenderness in her acromioclavicular joint, biceps and entire rotator cuff; that she had positive Speed, Yergason, and O'Brien tests; and significant pain with cross-arm adduction. His impression was right shoulder rotator cuff tear, possible labral tear, possible joint bone edema, and arthritis. He recommended right surgical arthroscopy (R. 116, 272).
Ms. Curry was admitted to Paoli Hospital on January 23, 2001. On January 26, 2001, Dr. DiStefano performed arthroscopy of the right shoulder with a debridement of her rotator cuff excisional arthroplasty of her acromioclavicular joint, anterior acromioplasty, subacromial bursectomy, and release of the coracoaromial ligament. His final diagnosis was partial thickness of the joint side tear of her supraspinatus, degenerative arthrosis of the acromioclavicular joint, and chronic impingement syndrome of her right shoulder (R. 115, 273, 339-353). Thereafter, Ms. Curry fractured her fifth metatarsal of her left foot and was placed in a short leg non-walking cast (R. 112-113). On February 15, 2001, Dr. DiStefano noted that Ms. Curry ambulated with a walker only sporadically throughout the day and had reduced strength in her right arm. He recommended a strengthening program (R. 198-99).
In March of 2001, Ms. Curry again was treated by Dr. Der Krikorian. She still had neck pain with occipital headaches. On neurological examination, Dr. Der Krikorian found diminished brachioradialis reflexes, hypesthesia in the C6 and C7 distribution, and limited motor examination of the right arm because of pain most likely postoperatively. His impression was C6 and C7 radiculopathies secondary to herniated discs and that she had an element of thoracic outlet syndrome (R. 150, 222).
On May 25, 2001, Ms. Curry was again admitted to Riddle Memorial Hospital under the care of Dr. Der Krikorian (R. 359-365). He performed an osteoplasty, anterior cervical microdisectomy at C5-6 and C6-7, and anterior cervical fusion at C5-6 and C6-7. Ms. Curry was discharged on May 29, 2001 with a diagnosis of herniated C5-6 and C6-7 discs, C6-7 radiculopathies, and cord compression (R. 358). An August 2001 cervical MIRI found a spinal fusion from C4-C7 (R. 368-369).
In August of 2001, Dr. Der Krikorian stated that Ms. Curry was recuperating well and that her symptoms were musculoskeletal in origin. He recommended she continue physical therapy (R. 367). On October 3, 2001, Dr. De Krikorian examined Ms. Curry and found hypoactive deep tendon reflexes in her upper extremities and mild hypesthesia in the C7 distribution on the right. He recommended she continue with home exercises (R. 366).
On October 18, 2001, Ms. Curry sought treatment with Dr. Steven Fischer due to right knee and low back pain (R. 370-371). Thereafter an MIRI was performed on Ms. Curry's lumbar spine which found a small central disc herniation at L5-S1 that effaced the anterior surface of the cord and anterior aspect of the 51 nerve roots and a mild bulge at L4-5 (R. 372-373).
The ALJ failed to properly evaluate the opinion of Ms. Curry's treating physician, Dr. Der Krikorian. An ALJ must accord significant deference to an assessment by a claimant's treating physician. Morales v. Apfel, 225 F.3d 310, (3d Cir. 2000); Gilliland v. Hecker, 786 F.2d 178, 183 (3d Cir. 1986). A treating physician's opinion will be given "controlling weight," if "well supported" by clinical and diagnostic techniques. 20 C.R.F. §§ 404.1527, 416.927; SSR 96-2p. "For a medical opinion to be well supported by medically acceptable clinical and laboratory diagnostic techniques. it is not necessary that the opinion be fully supported by all of the other evidence if no other substantial evidence in the record contradicts or conflicts with it.
Ms. Curry's treating physician's medical records documented that she would be unable to work due to her numerous surgeries, pain, and recovery time. Next, the ALJ clearly misinterpreted Dr. Der Krikorian's office notes. The ALJ erroneously stated that: "[Dr. Der Krikorian] did not agree with the claimant's statement to him on October 23, 2001 that `she cannot return to her job as a telephone operator because it involves prolonged sitting and moving her head sideways.' (Exhibit 14F at 4)" (R. 18). However, this office note actually stated:
Mrs. Judy Curry was evaluated in my office on the 23rd
day of October, 2001. Since August 30th, she reports
that her overall condition has remained unchanged She
has completed a full course of physical therapy and
her therapist has discharged her from the PT program.
She says she still has neck pain and stiffness that
she develops around fifteen minutes after a sitting
position, then she develops burning sensation across
the trapezius muscle. She denies any radiating pain to
the upper extremities. On occasion, she experiences
some numbness involving her forearm and hand on the
left side lasting for less than a minute.