United States District Court, Middle District of Pennsylvania
MALACHY E. MANNION, United States District Judge.
The record in this action has been reviewed pursuant to 42 U.S.C. §405(g) to determine whether there is substantial evidence to support the Commissioner’s decision denying the plaintiff’s claim for Social Security Disability Insurance Benefits, (“DIB”), under Title II of the Social Security Act (“Act”). 42 U.S.C. §§401-433. Upon review, the court will remand the instant action to the ALJ for further consideration of the plaintiff’s subjective complaints of pain and residual functional capacity in accordance with this memorandum.
I. PROCEDURAL BACKGROUND
The plaintiff protectively filed her application for benefits on March 23, 2010, in which she alleged an inability to engage in substantial gainful activity as of August 30, 2008, because of chronic neck and back pain, arthritis, headaches, Irritable Bowel Syndrome, (“IBS”), and depression. (TR. 95, 136).
After her claim was denied, (TR. 99-110), the plaintiff requested a hearing, which was held before an administrative law judge, (“ALJ”), on April 19, 2011. (TR. 34-61). The plaintiff was represented at her hearing before the ALJ by the same counsel representing her in this appeal. In addition to the plaintiff’s testimony, the ALJ heard the testimony of Gerald W. Keating, a vocational expert. (TR. 54-59).
On May 19, 2011, the ALJ issued her decision in which she found that the plaintiff met the insured status requirements of the Act through December 31, 2012; the plaintiff had not engaged in substantial gainful activity since her alleged onset date of August 30, 2008; the plaintiff has the following severe impairments: obesity, asthma, history of left hip sprain, degenerative disc disease of the cervical spine, and degenerative disc disease of the lumbar spine; the plaintiff does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appx. 1; the plaintiff has the residual functional capacity, (“RFC”), to perform sedentary work as defined in 20 C.F.R. §404.1567(a), except her ability to work at that level is reduced in that: (1) she must be afforded the option to sit or stand at will, (2) she is limited to occupations that require no more than occasional postural maneuvers, such as balancing, stooping, kneeling, crouching, crawling, and climbing on ramps and stairs, (3) she must avoid occupations that require pushing and pulling with the lower left extremity to include the operation of pedals; (4) she is limited to occupations that require no more than occasional overhead reaching, pushing and pulling with the upper extremities to include the operation of hand levers and overhead work; (5) she must avoid concentrated, prolonged exposure to fumes, odors, dusts, gases, chemical irritants, environments with poor ventilation, cold temperature extremes, excessive noise, vibration, extreme dampness, and humidity, (6) she is limited to occupations which do not require exposure to hazards such as dangerous machinery and unprotected heights, and (7) she is limited to occupations requiring no more than simple, routine tasks, not performed in a fast-paced production environment, involving only simple, work-related decisions, and in general, relatively few work place changes; the plaintiff was unable to perform any past relevant work; the plaintiff was born on January 12, 1965, and was 43 years old on the alleged disability onset date, which is defined as a younger individual age 18-44; the plaintiff has at least a high school education and is able to communicate in English; transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the plaintiff is “not disabled, ” whether or not the plaintiff has transferable job skills; considering the plaintiff’s age, education, work experience, and RFC, there are jobs that exist in significant numbers in the national economy that the plaintiff can perform; and the plaintiff had not been under a disability, as defined in the Act from August 30, 2008, through the date of the ALJ’s decision. (TR. 15-28).
The plaintiff filed a request for review of the ALJ’s decision with the Appeals Council, which was denied. (TR. 1-6, 12-14).
Currently pending before the court is the plaintiff’s appeal of the decision of the Commissioner of Social Security. (Doc. 1).
II. DISABILITY DETERMINATION PROCESS
A five step process is required to determine if an applicant is disabled for purposes of social security disability insurance. The Commissioner must sequentially determine: (1) whether the applicant is engaged in substantial gainful activity; (2) whether the applicant has a severe impairment; (3) whether the applicant’s impairment meets or equals a listed impairment; (4) whether the applicant's impairment prevents the applicant from doing past relevant work; and (5) whether the applicant's impairment prevents the applicant from doing any other work. See 20 C.F.R. §404.1520.
The instant action was ultimately decided at the fifth step of the process, when the ALJ determined that, while the plaintiff could not perform her past relevant work activity, her impairments did not prevent her from doing sedentary work activity with restrictions. (TR. 27-28).
III. EVIDENCE OF RECORD
The plaintiff was born on January 12, 1965, and was 43 years old at the time of her alleged onset date. (TR. 27). She has a high school education and completed two years of college education. (TR. 27, 243). Her past relevant work experience includes positions as a train operator and conductor for the New York City Transit Authority. (TR. 243).
The medical evidence of record indicates that while working on August 30, 2008, the plaintiff slipped and fell on a wet surface, with her left leg going outward, and she twisted her lower back on the left side. (TR. 243). The plaintiff was taken to the emergency room where she was evaluated. (Id.). X-rays were negative and the plaintiff was released. (Id.).
On September 2, 2008, Dr. Marc Parnes, the plaintiff’s family physician, examined the plaintiff and noted spasm and significantly limited bending and ambulation. (TR. 22, 507). Plaintiff had positive straight-leg raising on the left at 60 degrees and positive on the right at 80 degrees. Dr. Parnes diagnosed lumbosacral derangement, with sprain, strain, spasm, and bilateral sciatic radiculopathy; and a left hip sprain. (Id.). The plaintiff was prescribed Celebrex and physical therapy, and was referred for neurological consultation. (TR. 507).
On September 22, 2008, the plaintiff treated with Dr. R.C. Krishna, a neurologist. (TR. 23, 264). The plaintiff’s low back pain was rated at about 7-8 out of 10 when it was most intense. (Id.). The plaintiff complained of difficulty standing and sitting, and that Valsalva-type maneuvers, such as sneezing, straining, coughing, bending, and heavy lifting, tended to exacerbate her pain. (Id.). Plaintiff was noted to have 4/5 weakness in some of the muscles on the left side, positive straight-leg raising at 30 degrees on the left, and an antalgic gait. (TR. 23, 265). In addition, plaintiff was noted to have spasms in the cervical and lumbar spine and decreased range of motion. (TR. 265). The plaintiff’s sensation was normal, except for decreased pinprick sensation on the outer aspects of the left leg. (TR. 266). The plaintiff was assessed with a cervical and lumbar strain injury and a neuropathic pain syndrome. She was given prescription medication. (Id.).
On October 1, 2008, the plaintiff saw Dr. John S. Mazella, a Board-certified orthopedic surgeon, who performed an independent orthopedic evaluation of the plaintiff at the request of the Workers’ Compensation insurance carrier. (TR. 261). Upon examination, Dr. Mazella noted that the plaintiff appeared mildly uncomfortable during the examination and that she had a slight antalgic gait pattern with weight bearing on the left. (Id.). The plaintiff was able to do single leg stands with left hip and low back pain, and was able to perform heel and toe rises with left-sided pain. (Id.). Dr. Mazella noted mild spasm on the left with myofascial irritation and decreased range of motion, and negative straight-leg raising bilaterally. (Id.). The plaintiff could not complete the Patrick’s maneuver on the left because of left hip pain and her left hip range of motion was restricted to fifty percent of normal. (Id.). Left hip flexion produced some groin pain. (Id.). Dr. Mazella diagnosed the plaintiff with left hip groin adductor strain and lumbar sprain/strain without radiculopathy. (TR. 262). He indicated that the plaintiff was able to work, but was restricted to lifting, carrying, pushing and pulling of ten to twenty pounds. (Id.). It was further recommended that the plaintiff avoid twisting, climbing, and bending movements; she was limited in walking; she could not work at heights, operate a motor vehicle and/or mechanical equipment at work, or perform repetitive movements of the spine. (Id.).
In November 2008, Dr. Krishna administered a facet join injection. (TR. 23, 267).
On February 19, 2009, the plaintiff underwent an MRI on the cervical spine which showed bulging discs at C3-4 and C6-7, mild left neural foraminal stenosis at C3-4, and no significant spinal canal stenosis at any level. (TR. 275).
On April 15, 2009, Dr. Mazella reviewed the plaintiff’s February 2009 cervical spine MRI, as well as a February 2009 MRI of the plaintiff’s lumbar spine, which showed a bulging disc at L5-S1, with no significant neural foraminal or spinal canal stenosis at any level. (TR. 254-55, 450). Upon examination, Mr. Mazella noted no spasms in the plaintiff’s cervical or lumbar spine, but did note a decreased range of motion of the lumbar spine. (TR. 255). A Patrick’s test was positive on the left for left low back pain and negative for left hip pain. (TR. 256). Straight leg raising was negative. (Id.). The plaintiff was diagnosed with cervical strain/sprain without radiculopathy and lumbar strain/sprain with myofascial irritation trigger points on the left side, without radiculopathy. (Id.). Dr. Mazella opined that the plaintiff could work, but was restricted to lifting no more than twenty-five pounds, and should avoid twisting, climbing, and bending. (TR. 256-57).
On May 4, 2009, the plaintiff reported to Dr. Krishna pain relief for some time from the facet joint injection administered on November 4, 2008. (TR. 23, 267). At that time, a second facet injection was administered, after which the plaintiff again reported pain relief. (TR. 267).
On May 29, 2009, the plaintiff treated with Dr. Sebastian Lattuga, who performed a neurological examination and found that sensation was altered in the C6, L5-S1 nerve root distributions, along with positive straight leg raising test. Dr. Lattuga diagnosed the plaintiff with cervical bulges, ...