United States District Court, Western District of Pennsylvania
MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION
SUSAN PARADISE BAXTER UNITED STATES MAGISTRATE JUDGE
It is respectfully recommended that the Court deny Plaintiff’s Motion for Summary Judgment (ECF No. 9), grant Defendant’s Motion for Summary Judgment (ECF No. 11), and affirm the decision of the administrative law judge (“ALJ”).
1. Procedural History
Tanajae Raychelle Wallace, for John Ray Wallace (“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 applications 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. (“Act”). Plaintiff filed for benefits, claiming a complete inability to work as of February 28, 2009, due to a herniated disc, high blood pressure, and diabetes. (R. at 141-153, 178). His applications were denied (R. at 83-84, 87-110), and having exhausted all administrative remedies, this matter now comes before the Court on cross motions for summary judgment. (ECF Nos. 9, 11).
2. General Background
Plaintiff was thirty seven years old on the date of the ALJ’s decision and has a high school education. (R. at 37). Plaintiff’s job history included employment as a cook in a fast food restaurant and laborer. (R. at 48, 180).
3. Treatment History
One month prior to his alleged disability onset date, Plaintiff presented to the emergency room on January 12, 2009 and reported that he had been injured in a car accident and suffered abdominal contusions and chest injuries. (R. at 305-310). Mild tenderness of his left upper quadrant was found on physical examination, but his remaining physical examination was unremarkable. (R. at 305-306). Plaintiff exhibited a normal range of back motion with no tenderness found. (R. at 306). Plaintiff’s chest and hip x-rays revealed normal findings. (R. at 355-356). A CT scan of Plaintiff’s abdomen revealed the presence of a nodule on his liver. (R. at 355). Plaintiff was prescribed Vicodin for pain and was instructed to follow up with his physician for the possible liver lesion. (R. at 309-310).
Plaintiff followed up at Conneaut Valley Health Center on January 29, 2009. (R. at 343). Plaintiff’s ribs were tender on physical examination, and he was diagnosed with, inter alia, rib contusions. (R. at 343). On February 19, 2009, Plaintiff reported he was doing “ok.” (R. at 342). On September 24, 2009, Plaintiff complained of left rib pain, and tenderness was noted on physical examination. (R. at 341). He further complained of right shoulder pain, and exhibited a reduced range of motion. (R. at 341).
On December 1, 2009, Plaintiff complained of back pain and reported a history of a herniated disc suffered in 2006. (R. at 339). Plaintiff was subsequently hospitalized for three days in December 2009 for complaints of abdominal pain. (R. at 282-285). He was diagnosed with diabetic ketoacidosis, acute pancreatitis, hypertriglyceridemia, and type 2 diabetes mellitus, new onset. (R. at 282). Plaintiff’s blood pressure was well controlled on admission. (R. at 283). A CT scan of his abdomen revealed mild edema over the peripancreatic area suggesting pancreatitis. (R. at 282, 301). His diabetic ketoacidosis resolved with treatment. (R. at 283). Plaintiff was discharged in stable condition with new medications to manage his diabetes and instructed to check his blood sugar levels twice daily. (R. at 284). He was also prescribed Vicodin for pain for five days only. (R. at 284). When Plaintiff returned to Conneaut Valley Health Center for follow-up on December 28, 2009, his medications were adjusted. (R. at 337).
Plaintiff presented to the emergency room on February 9, 2010 and reported that he had fallen on icy stairs at home, twisting his right knee and back. (R. at 346). Physical examination revealed mild soft-tissue tenderness in the right lumbar area with no vertebral tenderness found. (R. at 346). Examination of Plaintiff’s right knee revealed mild tenderness and swelling, and some limited range of motion secondary to pain. (R. at 346). X-rays of Plaintiff’s right knee and lumbar spine were normal. (R. at 324, 345). He was prescribed Vicodin, Naproxen, and Flexeril on an as-needed basis. (R. at 347). He received chiropractic treatment for his complaints of low back pain on three occasions from February 19, 2010 through March 16, 2010. (R. at 321-322).
Plaintiff began treatment with Stuart Shapiro, M.D. on March 17, 2010 and reported a history of hypertension, diabetes, asthma, and back problems. (R. at 362). Plaintiff reported a history of a herniated disc, for which he had been referred to a surgeon and undergone chiropractic therapy. (R. at 362). He reported pain radiating down his left leg and occasionally his right leg that increased upon lifting. (R. at 362). Plaintiff indicated that he had applied for disability because he could no longer perform his factory job. (R. at 362). Plaintiff further reported that he previously twisted his knee and had varying degrees of pain and swelling. (R. at 362). Dr. Shapiro assessed him with diabetes, hypertension, and back and knee pain. (R. at 363). He continued Plaintiff on his medications, and recommended an MRI of Plaintiff’s knee and possibly an orthopedic evaluation. (R. at 363).
Plaintiff continued to be bothered by back and knee pain on April 1, 2010. (R. at 432). Dr. Shapiro refilled his medications and ordered an MRI of Plaintiff’s right knee. (R. at 432). An MRI of Plaintiff’s right knee dated April 12, 2010 was unremarkable. (R. at 367).
On May 21, 2010, Plaintiff was evaluated by Robert Woods, D.O. upon referral by Dr. Shapiro for his complaints of right knee and back pain. (R. at 381). Dr. Woods noted that Plaintiff’s knee x-rays and lumbar x-rays were unremarkable. (R. at 381). On physical examination, Dr. Woods found Plaintiff had a good range of right knee motion with mild crepitus, slight pain with forced extension, his ligaments were stable, there was no joint line tenderness, and no swelling. (R. at 381). Plaintiff’s straight leg raising test was negative bilaterally, although he had some lower back pain. (R. at 381). Plaintiff had tenderness in the lower lumbar regions bilaterally, and pain was elicited on forward flexion and side bending. (R. at 381). Plaintiff was neurovascularly intact in in his lower extremities. (R. at 381). Plaintiff reported that he had constant stiffness and had not seen a chiropractor in some time. (R. at 381). Dr. Woods referred him to a chiropractor for instruction in a home exercise program. (R. at 381). He diagnosed Plaintiff with right knee and low back pain, and found he had a good prognosis. (R. at 381).
Plaintiff returned to Dr. Shapiro on June 1, 2010 and reported bilateral swelling in his lower extremities. (R. at 431). Plaintiff’s blood pressure was slightly elevated, but he reported that his home readings had been “good.” (R. at 431). Trace edema was found on physical examination, but his pulses and circulation were intact. (R. at 431). He was ...