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Rushin v. Colvin

United States District Court, M.D. Pennsylvania

August 20, 2014

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


SYLVIA H. RAMBO, District Judge.

In this appeal from a decision of the Commissioner of Social Security denying Disability Insurance Benefits, Plaintiff claims the administrative decision concluding that she is not disabled as defined by the Social Security Act is not supported by substantial evidence. For the following reasons, the court will affirm the decision of the Commissioner.

I. Background

A. Procedural History

On September 3, 2010, Plaintiff Rebekah Rushin ("Plaintiff") protectively filed applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"), under Titles II and XVI of the Social Security Act, claiming that she suffers from a disability that began on August 31, 2009. ( See Doc. 10-5, pp. 2-3 of 20.) The Social Security Administration initially denied Plaintiff's application by decision dated March 2, 2011. (Doc. 10-4, pp. 2-10 of 33.) On March 25, 2011, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). ( Id. at p. 12 of 33.) ALJ Sridhar Boini held a hearing on January 11, 2012, at which Plaintiff and vocational expert Michele Georgio testified. (Doc. 10-2, pp. 23-43 of 81.) ALJ Boini issued an unfavorable decision to Plaintiff on April 9, 2012 ( id. at p. 7 of 81), and Plaintiff filed an appeal with the Appeals Council on May 3, 2012 ( id. at p. 5 of 81). The Appeals Council denied Plaintiff's request on June 18, 2013 ( id. at pp. 1-4 of 81), and Plaintiff commenced the instant action on August 9, 2013 (Doc. 1).

B. Evidence of Record

Plaintiff was 22 years old and considered a "younger individual"[1] under the Act at the time of the alleged onset date of her disability. ( See Doc. 10-5, p. 2 of 20.) She has a high school education and prior relevant work experience as a cashier. She lives with her mother and father. (Doc. 10-2, p. 36 of 81.)

On April 10, 2007, Plaintiff was involved in a motor vehicle accident and was treated at the Pocono Medical Center for severe back pain. (Doc. 10-7, pp. 5-6 of 19.) Radiological exams taken one week after the accident revealed that she suffered a lumbar spine fracture. (Doc. 10-7, pp. 13-14 of 19.)

On January 27, 2009, Plaintiff sought treatment at Coordinated Health Services ("CHS"), where she was seen by physiatrist Dr. Steven Mazza, M.D.[2] Dr. Mazza's examination revealed a right-side antalgic gait and limited lumbar range of motion. (Doc. 10-8, p. 35 of 49.) Plaintiff had 5/5 strength in all major muscle groups and in the lower extremities bilaterally. ( Id. ) However, her sensation was diminished in an L5-S1 distribution on the right. ( Id. ) Dr. Mazza reviewed an MRI of Plaintiff's lumbar spine, which demonstrated a central annular fissure at L3-4 with a central disk protrusion and lateral recess stenosis at L4-5, and a left paracentral disk herniation/protrusion with lateral recess and neuroforaminal stenosis at L5-S1. ( Id. ) Electrodiagnostic studies were normal with some elevation of the L5-S1 nerve roots. ( Id. )

During examinations conducted by Dr. Mazza in early 2010, Plaintiff continued to exhibit limited lumbar range of motion and a right-sided gait. (Doc. 10-8, pp. 21, 26, 31, 43 of 49.) Plaintiff's primary complaint concerned low back pain with extension into her right leg. ( Id. ) In an effort to treat her pain, Plaintiff received several epidural injections into her spine and an L3-4-5 medial branch block with minimal relief. (Doc. 10-9, pp. 7-12 of 77; see Doc. 10-8, pp. 26-27 of 49.)

On April 16, 2010, Plaintiff received a repeat MRI, which revealed multilevel spondylotic changes throughout the lumbar spine, a broad-based disc herniation at L3-4, and an anterior wedge deformity/fracture involving the L1 vertabrae. (Doc. 10-8, pp. 47-49 of 49.)

At an appointment with Dr. Mazza on May 13, 2010, Plaintiff continued to complain of low back pain extending into the right leg and rated her pain as a 9 out of 10. ( Id. at pp. 16-17 of 49.) Upon examination, Plaintiff was in no acute distress and her lower extremity strength and sensations were grossly intact bilaterally. ( Id. at p. 17 of 49.) However, she walked with a right-sided gait and had limited lumbar range of motion. ( Id. ) Dr. Mazza referred Plaintiff to a neurosurgeon and directed her to continue with pain medication. ( Id. )

Plaintiff's subsequent examinations with Dr. Mazza in June and July 2010, revealed the same objective findings as prior examinations. ( Id. at pp. 5-13 of 49.) Dr. Mazza's treatment notes reflected that Plaintiff was considering surgery due to her continued, severe lower back pain and functional limitations that were not improving with conservative and interventional care. ( Id. ) An EMG and nerve conduction velocity study conducted on July 30, 2010, provided normal findings. ( Id. at pp. 5-7.)

Plaintiff underwent a right-sided L4-5 and L5-S1 microdiskectomy on September 27, 2010, performed by Dr. Chris Lycette, M.D. (Doc. 10-9, pp. 63-64 of 77.) At her post-operative consultation on October 18, 2010, Plaintiff reported feeling better than she did pre-operatively, but noted that she continued to have "some right leg pains at times and some numbness/tingling along the right calf and foot." (Doc. 10-12, p. 33 of 98.) Dr. Lycette instructed her to start physical therapy and to follow up with him in six weeks. ( Id. at p. 34 of 98.)

On January 31, 2011, Dr. Linda Blouse, M.D. performed a consultative examination of Plaintiff at the request of the Social Security Administration. Plaintiff complained of increasing low back pain with radiation into her right leg since the time of her accident in 2007. (Doc. 10-12, p. 38 of 98.) She reported that she had undergone a laminectomy, but experienced no significant relief of her pain. ( Id. ) She described the pain as continuous but worsening with activity. ( Id. ) She tried to discontinue narcotics after suffering a seizure, but the pain was so severe that she had to continue the pain medication. ( Id. ) Plaintiff expressed difficulty with lifting and carrying more than a gallon of milk and with sitting and standing for more than ten minutes. ( Id. at p. 39 of 98.) Upon examination, Dr. Blouse observed that Plaintiff had decreased range of motion of the lumbar spine and a positive straight leg raise test on the right. ( Id. at p. 40 of 98.) Her deep tendon reflexes and strength were equal bilaterally. ( Id. ) Following her examination, Dr. Blouse completed a residual functional capacity assessment, wherein she indicated that Plaintiff could frequently lift and carry 2-3 pounds and occasionally lift and carry ten pounds. ( Id. at p. 43 of 98.) She further opined that Plaintiff could not sit for more than one hour cumulatively in an eight hour work day and could stand for less than one hour cumulatively in an eight hour work day. ( Id. )

On March 1, 2011, Dr. Elizabeth Kamenar, a consulting physician for the State Agency, completed a physical RFC assessment for Plaintiff. (Doc. 10-12, pp. 70-76 of 98.) Dr. Kamenar opined that Plaintiff would be capable of doing a range of light work, but with occasional postural limitations and environmental limitations. ( Id. )

On March 21, 2011, Plaintiff returned to Dr. Lycette and reported that she had experienced overall improvement in her back and leg pain with the pain now located mainly along the side of the thigh to the shin. (Doc. 10-12, p. 96 of 98.) She was working to wean herself off pain medications. ( Id. ) Upon examination, Dr. Lycette observed that Plaintiff was not in acute distress and had a normal gait. ( Id. at p. 97 of 98.) She had normal strength in her upper and lower extremities and no evidence of sensory ...

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