ROBERT E. GARRIS, Plaintiff,
CAROLYN COLVIN,  Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER OF COURT
TERRENCE F. McVERRY, District Judge.
Robert E. Garris, Jr. ("Plaintiff") brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c), for judicial review of the final determination of the Commissioner of Social Security ("Commissioner"), which denied his application for supplemental security income ("SSI") and disability insurance benefits ("DIB") under Titles II and XVI of the Social Security Act (the "Act"), 42 U.S.C. §§ 401-403, 1381-1383(f).
A. Plaintiff's age, vocational history, and alleged disability
Plaintiff was born on September 14, 1965, making him forty-three (43) years old on the date of his application and forty-five (45) years old at the time of the ALJ's decision. Under 20 C.F.R. §§ 404.1563 and 416.963, he is considered a "younger person." He earned a GED and has past work experience as a blacktop foreman, machine/press operator, a pallet production operator, and a general laborer. (R. 298, 302).
Plaintiff has not engaged in substantial gainful work activity since his disability onset date of October 30, 2008. (R. 34). His alleged disability stems from carpal tunnel syndrome, lumbar spine impairment, severe back pain, headaches, hypertensive cardiovascular disease/hypertension, depression, and insomnia. (R. 226-67, 296).
B. Medical Evidence
1. Treating Sources
The earliest indication of Plaintiff's impairments date back to a 1997 work injury, when a "board hit him in [the] back, shoulder/neck, " and subsequent rotator cuff surgery on the left arm (R. 360, 450). The primary focus of Plaintiff's medical records is, however, concentrated on the time period after 2006, when he allegedly woke up one day with a weak left arm. (R. 450). Throughout this time, Plaintiff's primary care was provided at Latrobe Family Health Center by John Horne, M.D., Stephen Mills, M.D., and Lydida Manzini, CRNP, with Dr. Horne acting as his primary care physician (hereinafter, the "treating physician"). (R. 356-79, 415-54, 497-504, 532-550).
In May 2007, Plaintiff underwent carpal tunnel release surgery from Matthew Wetzel, M.D., a colleague of Dr. Horne at Latrobe Family Health Center (R. 356-72). In a July 3, 2007 letter to Dr. Horne, Dr. Wetzel noted that Plaintiff had experienced good relief of his left hand numbness, 4/5 grip and muscle strength in his left hand and arm (R. 373). Dr. Wetzel also noted that a February 2007 EMG report showed "no evidence of cervical radiculopathy" and that a MRI showed a "C5-6 disc herniation with mild to moderate left foraminal stenosis" as well as a "C6-7 disc bulge with no significant foraminal narrowing." (R. 373). Dr. Wetzel concluded by suggesting a more conservative treatment route, opining that surgical intervention would not improve Plaintiff's symptoms. (R. 373). In October 2007, Plaintiff returned to Dr. Horne who adjusted his pain medications and referred Plaintiff to a pain clinic for a second opinion. (R. 376-77).
Between January and April 2008, Plaintiff was evaluated and treated by Brinda Navalgund, M.D., Rodney B. Dayo, D.O., and Louis R. Olegario, M.D., at Excela Health Pain Management Center by reference of Dr. Horne. (R. 381-88, 391-95, 401-04). All three physicians reported Plaintiff positive for upper extremity pain, neck pain, muscle weakness, tingling/burning/numbness neurology, difficulty with walking, difficulty with stairs, difficulty with sit to stand, difficulty with lifting, insomnia, restricted flexion and restricted range of motion. (R. 381-88, 391-95, 401-04).
On March 11, 2008, Dr. Dayo's physical examination revealed left upper extremity pain, neck pain, muscle weakness, and paraspinal muscle spasm. (R. 381-88). His neurological examination revealed gross motor testing at 5/5 bilaterally, normal sensation, and a normal gait. (R. 381-88). To manage his pain, Dr. Dayo performed an out-patient "[s]pinal cord stimulator trial with one lead placement" operation on Plaintiff. (R. 387-88). The record reflects that the spinal cord stimulator was removed one week later on March 18, 2008. (R. 382). In his treatment notes dated April 29, 2008, Dr. Horne observed that the spinal cord stimulator was removed because it felt "jittery." (R. 413).
The notes of an October 21, 2008 pain management consultation with Dr. Mills and Nurse Manzini describe pain in the left shoulder, limited/decreased range of motion, upper extremity strength of 3/5, lumbar tenderness, and Plaintiff's feeling that he "just gets by" with his current medication. (R. 448). On October 29, 2008, one day prior to the alleged disability onset date, Dr. Mills observed that x-ray's of Plaintiff's spine revealed, "moderate disc narrowing at C5-6, small to moderate marginal osteophytes, slight posterolisthesis at C5, " and the presence of "[m]inimal degenerative changes of the lower facet...." (R. 415-16). During a December 30, 2008 follow-up with Dr. Horne and Nurse Manzini, Plaintiff reported that he was unable to do much and nothing seemed to alleviate his pain despite his best efforts to stay as physically active as possible. (R. 447). Treating notes detail upper extremity strength remaining at 3/5, tenderness of the left shoulder, with an assessment of chronic shoulder pain with reflex sympathetic dystrophy/chronic lumbar pain, and instructions to return three months later in March. (R. 447).
After that visit, Nurse Manzini provided Plaintiff a jury release note, indicating he would be unable to participate in jury duty due to his inability to sit for long periods of time. (R. 418). Nurse Manizini also completed an "Upper Extremity Impairment Questionnaire" for Plaintiff in which she indicated that Plaintiff could lift and carry up to five pounds occasionally with his left arm; estimated that his symptoms would increase if he performed significant reaching, handling, or fingering; and, assessed the Plaintiff with "marked" limitations in his ability to use his left upper extremity to grasp, turn, twist, perform fine manipulation, and reach. (R. 419-24).
Plaintiff followed-up his pain management consultation in March 2009 and visited again in May and August 2009. Dr. Horne's treating notes from those visits indicate decreasing range of motion for the left shoulder and increasing pain in the left hand from reflex sympathetic dystrophy. (R. 444-46). Those same notes also indicate that Dr. Horne made several adjustments to the type and dosing of Plaintiff's medications during those visits. (R. 444-46).
On October 16, 2009, Dr. Horne completed a Lumbar Spine Impairment Questionnaire and a Bilateral Manual Dexterity Impairment Questionnaire. (R. 425-32, 432-38). On the first form Dr. Horne noted the following:
1. Plaintiff suffered from impairments of reflex sympathetic dystrophy of the left arm, chronic left shoulder pain, chronic neck pain, history of left carpal tunnel surgery, and low back pain;
2. Those diagnoses were supported by findings of limited range of motion of the left shoulder, tenderness of the left upper extremity, muscle spasm at the left subscapular region, sensory loss in the left hand, and muscle atrophy and weakness in the left upper extremity;
3. It was unlikely that Plaintiff's impairments would ever be asymptomatic;
4. Plaintiff would be able to sit for two hours and stand/walk for up to one hour in an eight-hour workday, required a sit/stand option every one to two hours, and would be able to lift up to five pounds frequently and ten pounds occasionally with only the right hand; and, as a result
5. It was unlikely that Plaintiff would be able to perform strenuous work.
(R. 425-32). On the second form, Dr. Horne noted that Plaintiff's impairments resulted in marked limitations in his ability to use his left hand for grasping, turning, or twisting objects, or use arms for reaching, and moderate limitations in fine manipulation. (R. 432-38). With respect to his right arm, Dr. Horne noted that Plaintiff's impairments resulted in moderate limitations in grasping, ...