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Coates v. Astrue

May 29, 2009


The opinion of the court was delivered by: Conti, District Judge



Pending before this court is an appeal from the final decision of the Commissioner of Social Security ("Commissioner" or "defendant") denying the claim of Adam J. Coates ("plaintiff") for supplemental security income ("SSI") under Title XVI of the Social Security Act ("SSA"), 42 U.S.C. §§ 1381-83; 20 C.F.R. Pt. 416. Plaintiff contends that the decision of the administrative law judge (the "ALJ") that he is not disabled and therefore not entitled to benefits, should be reversed because the decision is not supported by substantial evidence. Defendant asserts that the decision of the ALJ is supported by substantial evidence and should be affirmed. The parties filed cross-motions for summary judgment pursuant to Rule 56(c) of the Federal Rules of Civil Procedure. The court will grant summary judgment in favor of defendant and will deny plaintiff's motion for summary judgment because the ALJ's decision is supported by substantial evidence of record.

Procedural History

Plaintiff filed an application for SSI benefits on December 20, 2004. (R. at 20.) The disability report completed by the Social Security Administration on January 18, 2005, indicated that plaintiff alleged disability since August 4, 1992, but recommended the onset date be changed to December 31, 2004. (R. at 58.) Plaintiff alleged "disability since 12/31/04 due to left arm paralysis, severe head and neck trauma, and a left leg fracture." (R. at 21.) Plaintiff's medical records from Mercy Jeannette Hospital and Latrobe Area Hospital ("LAH") were considered.

(R. at 22.) Plaintiff's claim was denied on March 2, 2005, however, because he failed to attend a scheduled medical examination and disability could not be determined. (R. at 21.) The Notice of Disapproved Claim dated March 10, 2005 noted that the "examination was needed to fully evaluate [plaintiff's] condition." (R. at 22.) On May 11, 2005, plaintiff filed a timely written request for hearing by an administrative law judge ("ALJ"). (R. at 90-100.) A hearing was conducted on December 27, 2005, and was continued on April 3, 2006. (R. at 18-19.) Plaintiff, who was represented by counsel, testified at the hearing and a vocational expert ("VE") also testified. (R. at 176-216.)

On May 25, 2006, the ALJ gave notice of his decision that plaintiff was not disabled under § 1614(a)(3)(A) of the SSA. (R. at 10-17.) Plaintiff filed a timely written request to the Appeals Council on June 27, 2006, which was denied on March 11, 2008. (R. at 4-9.) Plaintiff filed this action seeking review of the ALJ's decision.

Plaintiff's Background and Medical History Testimony from Hearing

During the hearing before the ALJ on April 3, 2006, plaintiff testified that in 1992 he was involved in a motorcycle accident in which his left arm was severely damaged ("first injury").

(R. at 187, 199.) He has a steel plate in his left arm, which is much smaller than his right arm. (R. at 188.) He was originally left handed, but he now wears a brace on his left arm at all times. (Id.) He stated that he cannot do anything with his left hand, although he can move his left shoulder. (Id.) In addition to the injury to his shoulder, veins and arteries were taken out of his leg for surgery on his left arm, and he injured his head, upper left leg, neck, and lower back. (R. at 189, 196, 199.)

During the hearing, plaintiff testified that in 1999 he was involved in an automobile accident in which he broke bones in both of his ankles ("second injury"). (R. at 200.) Doctors reconstructed the broken bones with steel screws and plates that are still in his body. (Id.) He was hospitalized for a week, spent another four to six weeks in a nursing home, and was in a wheelchair for several months. (R. at 200-01.)

Plaintiff testified that in 2004 he fell over a hill and suffered a compound fracture in his leg ("third injury"). (R. at 191-92.) Doctor Dolecki, who treated him for the third injury, prescribed a walker, which he cannot use, and a wheelchair, which he received from his friend.

(R. at 204-05.)

Plaintiff testified that due to muscle spasms he cannot stand for more than three minutes at a time without having to sit down. (R. at 192.) He must lie down after sitting for prolonged periods. (R. at 192-93.) During the hearing, he sat for what he estimated to be ten to fifteen minutes and testified that it was very painful. (R. at 192.) He has trouble sleeping, and takes naps four or five times a week for an hour at a time. (R. at 193-94.) He has weakness and numbness down his entire left side. (R. at 196.) His lower back is thrown out of place when he lifts with his right arm. (R. at 199.)

Plaintiff testified that he takes Oxycontin*fn1 for his pain. (R. at 194.) He attended a pain clinic at Westmoreland Regional Hospital with Dr. Navalgund in 2005 and currently attends a pain clinic with Dr. Jabbour, who sees him once every couple of months. (R. at 148-62, 194-95.) He took Zoloft, an anti-depressant, and might be prescribed Lexapro, another anti-depressant.

(R. at 197-98.) At the time of the hearing, he had been without pain medication for three days and testified that his pain was "really bad." (R. at 203.)

Records from Latrobe Area Hospital

In 2004, plaintiff received treatment for his third injury at LAH. (R. at 102.) Dr. Dolecki, the physician that evaluated plaintiff, diagnosed him with fractures to his left tibia and left proximal fibia. (R. at 103.) Dr. Dolecki stated that the reason for plaintiff's hospitalization was a fall sustained at a rock concert. (Id.) Plaintiff's tibia fracture was treated with an intramedullary nail device and the fibula was treated with closed means. (Id.) X-rays performed in the LAH radiology department revealed no abnormalities in plaintiff's pelvis, cervical spine, right foot, or chest. (R. at 105-06, 108, 110.) An x-ray of plaintiff's right ankle, however, revealed a plate and multiple screws to the distal tibia, which the radiologist, Dr. Hoffman, identified as an old fixation of a distal tibial fracture. (R. at 107.) An x-ray of plaintiff's left lower leg showed screws in the talus, along with the fractures to his tibia and fibula. (R. at 109.) Records from Westmoreland Regional Hospital

Plaintiff attended the Westmoreland Regional Hospital ("WRH") Pain Management Center four times in 2005. (R. at 148-62.) During the initial visit, on March 4, 2005, Dr. Brinda Navalgund, the attending physician, reported that plaintiff's chief complaint was pain in his left arm, head, and back. (R. at 159.) At the time, plaintiff was not taking any medication. (Id.) He relieved his pain by taking epsom salt baths, getting massaged with tiger balm, and smoking marijuana. (Id.) He stated that ibuprofen did nothing for his pain. (Id.) 2008). The most frequent side effects include "constipation, nausea, somnolence, dizziness, vomiting, pruritus, headache, dry mouth, sweating, and asthenia." Id. at 2683.

Dr. Navalgund's physical examination identified no abnormal curvatures or deformities of plaintiff's lumbosacral, cervical, or thoracic spine. (R. at 161.) She noted that the range of motion in his cervical spine was decreased and that there was tenderness with palpation of his left trapezius. (Id.) Her examination of plaintiff's left arm revealed a decreased range of motion in the shoulder, decreased musculature in the elbow, and multiple scars and a decreased range of motion in the wrist. (Id.) Her examination of plaintiff's left knee revealed scars, tenderness, and decreased range of motion. (Id.) She noted that plaintiff's right leg was bigger than his left leg and that there was atrophy in his left arm. (Id.)

Dr. Navalgund's diagnoses were chronic controlled neuropathy*fn2, chronic controlled myofascial pain/myalgia/myositis, chronic controlled lumbar pain/lumbago*fn3 radiating down plaintiff's lower extremities, and chronic controlled general pain in his left arm and both legs.

(R. at 162.) She prescribed MS Contin*fn4 for plaintiff and gave him samples of Celebrex*fn5 and Neurontin*fn6. (Id.) She planned to recommend physical therapy for generalized deconditioning at a future visit. (Id.)

At plaintiff's second visit, on April 5, 2005, he reported that the MS Contin seemed to be helping his pain, noting that he could "be a little more active with the kids." (R. at 156.) The doctor again prescribed MS Contin for plaintiff, noting "[w]e will see if headaches subside with the use of morphine for another month. (R. at 158.)

At his third visit, plaintiff reported that he had bought a home gym and was trying to work on a strengthening program. (R. at 152.) Dr. Navalgund switched plaintiff's medication from MS Contin to Oxycontin after complaints from plaintiff that MS Contin was causing headaches and constipation. (R. at 152, 154.)

At plaintiff's fourth visit, Dr. Navalgund reported that plaintiff's lower back and gait were improved. (R. at 150.) A range of motion test of his lumbosacral spine was tolerated better and he was able to forward flex to touch his toes. (Id.) ...

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