United States District Court, Middle District of Pennsylvania
Hon. John E. Jones III, Judge
Plaintiff Mark Alan Laforge has filed this action seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying Laforge's claim for social security disability insurance benefits.
Disability insurance benefits are paid to an individual if that individual is disabled and “insured, ” that is, the individual has worked long enough and paid social security taxes. Laforge met the insured status requirements of the Social Security Act through December 31, 2014. Tr. 47.
Laforge filed his application for disability insurance benefits on August 4, 2010, alleging that he became disabled on September 21, 2009. Tr. 106. Laforge had been diagnosed with several impairments, including depression, obesity, “chronic back pain, ” a herniated disc of the lumbar spine, sciatica, and lumbar radiculopathy. Tr. 47, 232, 344. On October 5, 2010, Laforge's application was initially denied by the Bureau of Disability Determination. Tr. 61.
A hearing was conducted by an administrative law judge (“ALJ”) on October 11, 2011, where Laforge was represented by counsel. Tr. 13-39. On November 10, 2011, the ALJ issued a decision denying Laforge's application. Tr. 45-54. On June 7, 2013, the Appeals Council declined to grant review. Tr. 1. Laforge filed a complaint before this Court on August 23, 2013, and this case became ripe for disposition on February 4, 2014, when Laforge filed a reply brief Laforge appeals the ALJ's determination on three grounds: (1) the ALJ erred in rejecting the opinions of Laforge's treating physicians, (2) the ALJ improperly discounted Laforge's credibility, and (3) the determination at step five of the evaluation process was not supported by substantial evidence. For the reasons set forth below, this case is remanded to the Commissioner for further proceedings.
Statement of Relevant Facts
Laforge was forty-nine years of age at the time the ALJ rendered his decision; he has a high school education, and is able to read, write, speak and understand the English language. Tr. 132, 134. Laforge's past relevant work experience included work as: a machine operator, which is classified as medium, skilled work; a material handler, which is classified as heavy, semiskilled work; a forklift operator, which is medium, semiskilled work; a wood worker, which is medium, semiskilled work; and as a warehouse worker, which is medium, unskilled work. Tr. 28-29.
A. Laforge’s Physical Impairments
Laforge presented to the Orange Regional Medical Center emergency room on September 21, 2009, complaining that he had “pulled his back out” while lifting boxes at work. Tr. 198-219. Laforge had positive bilateral paralumbar tenderness. Tr. 199. His gait was normal, he had a negative bilateral straight leg test, no lower extremity weakness, and his strength and reflexes were within normal limits. Id. Laforge was also able to move all of his extremities without difficulty. Tr. 216.
On September 24, 2009, Laforge was examined by his treating physician, Alexander Gapay, M.D. Tr. 297. Laforge reported pain in his lower back that radiated to the lower left extremity. Id. Dr. Gapay noted significant muscle spasms and pain in the lumbar spine. Tr. 298. Laforge's ability to flex his hip reduced by fifty percent, he experienced pain during heel-to-toe walking, and a straight leg raise test was positive on the left side. Id.
X-rays taken that day revealed no evidence of fracture or dislocation, and Laforge's intervertebral disc spaces were “well preserved at all levels.” Tr. 296. The x-rays did show several large osteophytes in the lower thoracic region at the T10-11, T11-12, and T12-L1 levels, as well as a “loss of height of the T11 vertebral body” which was indicative of a fracture. Id. On October 8, 2009, an MRI was performed on Laforge's lumbar spine. Tr. 307. The MRI demonstrated a small foraminal disc herniation at the L4-5 level, which caused “slight left foraminal narrowing in the region of the exiting L4 nerve root.” Id.
On October 12, 2009,  Laforge reported that he continued to experience low back pain ranging from a four out of ten to a ten out of ten. Tr. 308. Laforge had tenderness between the L4 and S1 vertebrae, his lumbar flexion range of motion was limited to fifty percent its normal range, and he experienced pain with heel-to-toe walking. Tr. 309. Dr. Gapay diagnosed Laforge with a herniated disc at the L4-5 lumbar spine level. Id.
On October 26, 2009 Dr. Gapay noted that Laforge had a positive straight leg raise test on the left side, pain at the L4-S1 region, and 1 reflexes in the lower extremities. Tr. 314. Laforge's lumbar flexion and extension range of motion was limited to less than half its normal range, he was able to flex his hip to less than fifty percent of normal, and he experienced discomfort during heel-to-toe walking. Id. Laforge complained that his radiating low back pain occasionally reached ten out of ten; he had trouble getting out of bed and tying his shoes. Tr. 313. Dr. Gapay noted that physical therapy was not helping significantly and medications were not effective in controlling Laforge's pain. Tr. 314. He opined that Laforge had a “constant relationship” with pain, and had a marked partial disability. Id.
On November 4, 2009, Laforge presented to Sushil Dhawan, M.D. for an orthopedic consultation. Tr. 317. Laforge stated that his low back pain level was a four or five out of ten; this pain radiated to his lower left extremity. Id. A straight leg raise test was positive for pain at seventy degrees on the left side, and there was tenderness in the lumbosacral region. Tr. 318. Laforge's range of motion in his lumbar spine was reduced to: forty-five degrees out of sixty in the flexion; fifteen degrees out of twenty-five in the extension; twenty degrees out of twenty-five in the right lateral flexion; and fifteen degrees out of twenty-five in the left lateral flexion. Id. Laforge had five out of five strength, 2 reflexes, and no sensory deficits. Id.
On November 6, 2009, Laforge presented to Thomas Colavito, D.C. for an initial chiropractic evaluation. Tr. 511. Laforge experienced pain in his lumbar region and left leg, as well as numbness and tingling in his left leg. Tr. 512.
Laforge had weakness in his heel walk and toe extension, pain and tenderness in his lumbar region, and a restricted range of motion in his lumbar flexion. Tr. 512-13. Dr. Colavito noted that Laforge limped when he walked, and opined that Laforge was unable to return to work. Tr. 513-14.
A November 7, 2009 x-ray of the lumbosacral spine revealed adequately maintained intervertebral disc spaces and no evidence of fracture. Tr. 321. The x-ray did demonstrate a mild spinal curve abnormality and mild degenerative anterior spurring at the T12-L1 level. Id.
On November 16 and 18, 2009, Laforge presented to Dr. Gapay complaining of radiating pain ranging from five to eight out of ten. Tr. 322, 327. Laforge also complained that his medication made him drowsy. Tr. 327. On November 16, Laforge's hip flex was less than fifty percent normal; by November 18 it was less than twenty-five percent normal. Tr. 323, 328. Dr. Gapay diagnosed Laforge with left neuroforaminal stenosis accompanied by radiculopathy. Tr. 323, 328.
On November 17, 2009, Laforge presented to Vladimir Salomen, M.D. for a pain management consultation. Tr. 324. Dr. Salomen noted a decreased range of motion in the lumbar flexion; Laforge had a normal range of motion in the lumbar extension, though he did experience pain at the end of the motion. Tr. 326. A straight leg raise test was positive on the left side and a slump test was positive, though Laforge had 4 out of 5 strength in his lower extremities. Id. Dr. Salomen diagnosed Laforge with low back pain “likely secondary to left L5 radiculopathy” and scheduled ...