The opinion of the court was delivered by: David Stewart Cercone United States District Judge
Michael T. Townsend ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying his application for supplemental security income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381 -- 1383f ("Act"). This matter comes before the court on cross motions for summary judgment. (ECF Nos. 9, 11). The record has been developed at the administrative level. For the following reasons, Plaintiff's Motion for Summary Judgment is GRANTED, in part, and DENID, in part, and Defendant's Motion for Summary Judgment is DENIED.
Plaintiff applied for SSI on August 14, 2008, claiming that he was disabled as of March 15, 2008, due to functional limitations stemming from physical impairments. (R. at 12).*fn1
Plaintiff was initially denied benefits on March 25, 2009. (R. at 46 -- 50). A hearing was scheduled for August 27, 2009, and Plaintiff, represented by counsel, appeared to testify. (R. at 314 -- 36). A vocational expert also testified. (R. at 314 -- 36). The Administrative Law Judge ("ALJ") issued his decision denying benefits to Plaintiff on September 17, 2009. (R. at 12 -- 19). Plaintiff filed a request for review of the ALJ's decision by the Appeals Council, which was denied on April 18, 2011, making the decision of the ALJ the final decision of the Commissioner. (R. at 4 -- 6).
Plaintiff filed his Complaint in this court on June 28. 2011. (ECF No. 3). Defendant filed his Answer on September 12, 2011. (ECF No. 4). Cross motions for summary judgment followed. (ECF Nos. 9, 11).
III.STATEMENT OF THE CASE
Plaintiff claimed he was disabled due to limitations stemming from lumbar disc disease, lumbar spinal stenosis, and general lower back pain -- all progressively worsening. (R. at 63, 82). His ability to lift and carry objects, and to sit, stand, and engage in other postural movements, was allegedly quite limited. (R. at 63, 79). Plaintiff stated that he stopped working on July 8, 2004, because his conditions had become so severe that he could no longer perform his job. (R. at 63). He had not worked since that time. (R. at 63). Plaintiff's prior employment consisted primarily of labor, construction, and mechanical work. (R. at 64).
Plaintiff was born on July 17, 1965. (R. at 317). At the time of his administrative hearing, Plaintiff was forty four years of age. (R. at 317). Plaintiff did not complete high school, but did earn a GED. (R. at 317). He received no post-secondary education, but did receive vocational training at the Pittsburgh Diesel Institute. (R. at 68). At the time of his administrative hearing, Plaintiff lived in an apartment with his wife, three daughters, and grandson. (R. at 74, 320 -- 21).
In his own functional report of day-to-day activity, Plaintiff explained that he had difficulty sitting and standing for prolonged periods due to pain, and spent much of his day alternating positions. (R. at 74). He also needed to lie down several times a day. (R. at 74). His pain was often so severe it woke him at night. (R. at 75). The pain experienced was constant, and required the use of prescription medication for relief. (R. at 82 -- 83). While he was capable of self-care, he noted that he occasionally required help tying his shoelaces. (R. at 75).
Plaintiff no longer cooked, and was relegated to only very light housework. (R. at 76). Plaintiff preferred to leave his apartment at least once a day. (R. at 77). He maintained a driver's license and was capable of driving a vehicle. (R. at 77). Plaintiff maintained that he could not drive alone, however, because of a fear that his back would lock up and interfere with his driving. (R. at 77). He also refused to drive long distances. (R. at 77). Plaintiff had given up most hobbies, and only occasionally socialized with his son or brother at their respective homes. (R. at 78). Plaintiff utilized a cane to ambulate, although it had not been prescribed by a physician. (R. at 80).
Plaintiff completed a "Pain Diary" to catalog pain and limitation related to his back conditions over a period spanning April 2009 through July 2009. (R. at 102 -- 207). On a pain scale of 1 -- 10, Plaintiff typically indicated his daily pain to range between 8 and 10. (R. at 102 -- 207). Plaintiff also reported poor sleep, fairly high fatigue, and significant weakness. (R. at 102 -- 207). His ability to maintain balance was somewhat affected by his back conditions, and his ability to walk was seriously affected. (R. at 102 -- 207). Plaintiff typically experienced shooting and burning pain in his hips and legs, as well as numbness and "pins and needles." (R. at 102 -- 207).
An x-ray of Plaintiff's lumbosacral spine was taken on April 1, 2008. (R. at 220). The xray revealed the presence of significant degenerative changes at the L5 -- S1 level of the spine with respect to both disc space and facet and degenerative hypertrophic changes. (R. at 220). Underlying spinal canal stenosis was of concern. (R. at 220). An MRI of Plaintiff's lumbar spine was taken on April 14, 2008. (R. at 216). The image report stated that Plaintiff exhibited only mild central stenosis at L5 -- S1 due to a diffuse disc bulge. (R. at 216). At L4 -- L5, Plaintiff had moderate stenosis, with accompanying degenerative facet joint changes and hypertrophy of the posterior ligaments. (R. at 216). At L3 -- L4, there was mild central disc bulging causing only mild stenosis. (R. at 212 -- 15).
Plaintiff visited Curt Conry, M.D. for a neurosurgical evaluation on June 13, 2008. (R. at 209 -- 210). Dr. Conry noted Plaintiff's complaints of pain and limitation, and also noted that Plaintiff alleged experiencing such pain for approximately twenty years -- progressively worsening over time. (R. at 209 -- 210). Plaintiff could cite to no particular triggering event, however. (R. at 209 -- 210). Plaintiff reported not working for several years due to his pain. (R. at 209 -- 210). He engaged in some physical therapy which allegedly helped for a brief period.
(R. at 209 -- 210). Formal pain management had not been attempted, but Plaintiff did take pain medication in the form of hydrocodone and ibuprofen. (R. at 209 -- 210).
Upon examination, Dr. Conry observed that Plaintiff was unhealthy in appearance, and significantly overweight. (R. at 209 -- 210). Plaintiff's strength in all muscle groups and his sensation to light touch was full. (R. at 209 -- 210). Feeling in his feet was decreased, however.
(R. at 209 -- 210). Plaintiff's reflexes were not particularly strong in his bilateral extremities, he had severe pain on palpation of his lumbar spine, and he had severe pain on straight leg raises to forty five degrees. (R. at 209 -- 210). Yet, he could ambulate well, and could walk on his heels and toes without significant difficulty. (R. at 209 -- 210). Dr. Conry interpreted recent MRI scans to show severe degenerative disc disease at the L5 -- S1 level of the spine, associated with osteophyte/disc complex causing severe bilateral L5 nerve root compression. (R. at 209 -- 210).
Dr. Conry's diagnosis was L5 -- S1 severe degenerative disc disease with associated spinal and foraminal stenosis. (R. at 209 -- 210). Dr. Conry suggested that Plaintiff was a candidate for posterior lumbar interbody fusion, but wished to attempt more conservative treatments first. (R. at 209 -- 210). Plaintiff was to try physical therapy, ...