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Kristie Hartman v. Michael J. Astrue

October 25, 2012

KRISTIE HARTMAN, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: McLAUGHLIN, Sean J., District Judge.

MEMORANDUM OPINION

I.INTRODUCTION

Kristie Hartman ("Plaintiff"), commenced the instant action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"), denying her claims for disability insurance benefits ("DIB") and supplemental security income ("SSI) under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401, et seq. and § 1381 et seq. Plaintiff filed her applications on May 13, 2008 alleging disability since May 1, 2007 due to "[d]egenerative deteriorating back disease" (AR 116-125; 135 ).*fn1 Her applications were denied (AR 58-66), and following a hearing held on October 9, 2009 (AR 34-54), the administrative law judge ("ALJ") issued his decision denying benefits to Plaintiff on December 8, 2009 (AR 21-29). Plaintiff's request for review by the Appeals Council was subsequently denied (AR 1-4), rendering the Commissioner's decision final under 42 U.S.C. § 405(g). The instant action challenges the ALJ's decision. Presently pending before the Court are the parties' cross-motions for summary judgment. For the reasons that follow, the Plaintiff's motion will be denied and the Commissioner's motion will be granted.

II.BACKGROUND

Plaintiff was 36 years old on the date of the ALJ's decision (AR 27). She has a high school education and past work experience as a school bus driver and cook (AR 136; 140).

On May 21, 2007, Plaintiff was seen by Laura McIntosh, M.D. and complained of bilateral hand pain, intermittent left foot numbness, and back pain (AR 247). On physical examination, her neck range of motion was within normal limits (AR 248). She had 4/5 strength in her upper extremities and her deep tendon reflexes were normal (AR 248). Dr. McIntosh reported Plaintiff had decreased sensation to light touch on the whole aspect of her hand, and the medial aspect of her forearm to the elbow bilaterally (AR 248). No tenderness was found along her lumbar spinous processes, but some tenderness was found over her sacrum (AR 248). She exhibited a limited lumbar range of motion with forward flexion and extension due to pain, but was able to sit and stand without using her arms (AR 248). Dr. McIntosh reported that her sensory examination was within normal limits (AR 248). Cervical spine x-rays revealed some narrowing of the C4-5 disc space with some foraminal narrowing (AR 249). Dr. McIntosh ordered additional testing (AR 249).

A cervical MRI dated June 2, 2007 revealed a mild disc bulge at the C3-4 and C5-6 levels with no evidence of spinal cord or nerve root impingement (AR 346). An EMG revealed median nerve impingement indicative of carpal tunnel syndrome (AR 243). An MRI of Plaintiff's lumbar spine dated June 22, 2007 revealed mild degeneration and bulge of the L3-4 disc with no disc herniation or canal stenosis (AR 243; 345).

Plaintiff returned to Dr. McIntosh on July 16, 2007 and continued to complain of bilateral hand numbness and left leg numbness and pain (AR 241). Plaintiff further complained of left foot pain (AR 241). Plaintiff reported difficulty with daily activities, walking, and climbing stairs (AR 241). On physical examination, Plaintiff's wrist range of motion was limited bilaterally in all directions, she had normal grip strength, and her sensation testing was "abnormal" (AR 242). Her lumber range of motion on flexion, extension, side bending and twisting was within normal limits, although some pain was noted on forward flexion (AR 242). Dr. McIntosh diagnosed Plaintiff with bilateral hand tingling, cervical and lumbar disc degeneration, and carpal tunnel syndrome (AR 242). She was referred to a hand surgeon and physical therapy was prescribed for her back pain (AR 243).

Plaintiff underwent a course of physical therapy between July 2007 and September 2007 (AR 181-200). At her initial evaluation, Plaintiff reported limitations in walking, bending, lifting, standing, sitting, driving, and grasping (AR 199-200). Treatment notes revealed that Plaintiff exhibited good lumbar and cervical alignment, her spine mobility improved, and she reported that her pain decreased (AR 181-200).

Plaintiff returned to Dr. McIntosh on August 11, 2007 and reported an improvement in her pain following physical therapy, but claimed it returned with activity (AR 236). She also reported mild improvement in her neck range of motion (AR 236). On physical examination, Dr. McIntosh found that her neck and back range of motion were normal, and her upper and lower extremity strength was within normal limits (AR 237-238). Dr. McIntosh further found that her sensation and reflexes were intact in her lower extremities (AR 238). Plaintiff's diagnosis remained the same, and Dr. McIntosh reported that she had modest improvement in her neck and back pain with physical therapy (AR 238). Home exercises were added to her treatment regimen, and she was scheduled to see an orthopedic surgeon for her carpal tunnel syndrome (AR 238).

On September 17, 2007, Plaintiff complained of lumbar pain, bilateral hand numbness and left foot/calf pain (AR 233). She reported minimal benefit from physical therapy and claimed she continued to have numbness and weakness in her lower extremities (AR 233). Physical examination revealed limited lumbar range of motion due to pain, and limited ankle range of motion, with some tenderness noted in her foot on palpation (AR 234). X-rays of her foot and ankle showed no bony abnormality, fracture or dislocation (AR 235; 343). Plaintiff reported that she preferred to continue with conservative treatment for her back instead of physical therapy (AR 235). She was instructed on range of motion exercises for her foot and ankle pain (AR 235).

On October 1, 2007, Plaintiff was seen by Patrick Williams, D.O. for evaluation of her bilateral carpal tunnel syndrome (AR 225-226). Dr. Williams recommended she undergo carpal tunnel release surgery (AR 226).

Plaintiff returned to Dr. McIntosh on October 22, 2007 and complained of back pain and bilateral knee pain (AR 221). It was noted that she was seeing Paul Carnes, M.D., for epidural injections for her back pain (AR 224). She was instructed on knee range of motion and strengthening exercises for her knee pain (AR 224).

On December 19, 2007, Dr. Carnes administered a lumbar epidural injection and when seen by Dr. McIntosh on December 22, 2007, Plaintiff had no back pain complaints (AR 202; 218). Dr. McIntosh reported that Plaintiff had excellent results from the epidural injection; her pain was almost gone and she had no numbness or tingling in her legs (AR 218). It was noted that Plaintiff had undergone carpal tunnel release surgery on her right hand which had improved her symptoms (AR 218).

An MRI of Plaintiff's lumbar spine dated January 12, 2008 was unremarkable (AR 342). Compared to her previous MRI performed in June 2007, the mild bulge at L3-4 was stable, no new disc pathology was seen, and there was no nerve root impingement (AR 342).

Plaintiff underwent a consultative examination performed by Daniel Muccio, a neurosurgeon, on January 29, 2008 (AR 205-207). Plaintiff complained of low back pain that occasionally radiated into her left leg, but denied any lower extremity weakness (AR 205). She reported undergoing physical therapy, injection therapy and chiropractic therapy, and at the time of the evaluation took Ibuprofen as needed for pain (AR 205). Dr. Muccio reported that her neurological examination was normal, her motor strength was 5/5 in her lower extremities, there was no foot drop, her deep tendon reflexes were 2 and symmetrical, and her gait was steady (AR 206). Conservative treatment was discussed, including physical therapy, anti-inflammatory medication, core strengthening and weight loss (AR 206).

Plaintiff returned to Dr. McIntosh on February 25, 2008 and complained of back pain (AR 213). Plaintiff reported that she had undergone epidural injection therapy without significant improvement (AR 213). She claimed she experienced pain with daily activities and extended sitting, but was comfortable sitting in a hard chair or rocker (AR 213). She took Advil at night to help her sleep (AR 213). Dr. McIntosh noted that her repeat MRI revealed no significant change and that Dr. Muccio felt she was not a surgical candidate (AR 213). Plaintiff reported that her right hand was doing well but she complained of right elbow pain (AR 213). On physical examination, Dr. McIntosh reported that her lumbar range of motion, sensation, reflexes and strength were all within normal limits (AR 215). She exhibited mild tenderness at the L5, S1 levels (AR 215). Her upper extremity examination was also reported as normal, and no effusion, redness or warmth of joint was observed in her right elbow (AR 215). She was diagnosed with lumbago, lumbar disc degeneration, and lateral epicondylitis (AR 216). Dr. McIntosh recommended a pain management consult for her back pain (AR 216). She further prescribed wrist splints, and instructed Plaintiff on wrist strengthening and range of motion exercises for her carpal tunnel symptoms (AR 216).

Plaintiff completed a "Function Report" on a form supplied by the Commissioner on June 18, 2008 (AR 145-152; 160-161). She reported that she took care of her children, which included getting them ready for school and helping them with their homework (AR 146). She further reported that she took care of her pets, cooked, did the laundry, cleaned the house, grocery shopped, watched television, read, and played games with her children (AR 145-148). Plaintiff reported she could lift ten pounds, and walk 100 feet before needing to stop and rest (AR 150). She further reported that her ability to engage in postural activities was dependent upon her pain level (AR 150). She indicated that she wore a back brace but did not need an assistive device to walk (AR 151; 161).

On July 21, 2008, Juan Mari-Mayans, M.D., a state agency reviewing physician, reviewed the medical evidence of record and opined that Plaintiff could lift and carry 20 pounds occasionally and 10 pounds frequently; stand and walk for three hours in an 8-hour workday; and sit for six hours in an 8-hour workday (AR 336). He further opined that Plaintiff could only occasionally climb, balance, stoop, kneel, crouch, and crawl (AR 337). Dr. Mari-Mayans concluded that Plaintiff's claimed restrictions were only partially credible in light of the medical evidence of record (AR 340).

On August 5, 2008, Plaintiff was evaluated by Jonathan Costa, M.D., a physiatrist, at Dr. McIntosh's request (AR 406-408). Plaintiff reported low back pain radiating to her lower extremities (AR 406). She claimed that her pain was alleviated by lying down and was aggravated by sitting or standing (AR 406). On physical examination, Dr. Costa reported that Plaintiff was able to sit and move "well" and her gait was within functional limits (AR 407). There was some decrease in sensation in her lower extremities, but her strength was intact with minimal pain on hip flexion (AR 407). Dr. Costa diagnosed Plaintiff with, inter ...


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