United States District Court, M.D. Pennsylvania
MARTIN C. CARLSON, Magistrate Judge.
The plaintiff in this case, Gerald Squier, was 48 year old man with a documented history of severe spinal impairments, including degenerative disc disease of the lumbar and cervical spine. (Tr. 20.) Squier's spinal pain and disability has been the subject of opinions and medical documentation from three different treating sources. One of these treating sources, Dr. Mikhail Artamonov, opined in April of 2011, that Squier's pain and injuries resulted in "significant functional disability" for the plaintiff. (Tr. 676.) Another treating physician, Dr. Behzad Maghsoudlou, Squires' treating neurologist, has twice submitted impairment questionnaires in May and November of 2012 in which this physician expressed the view that Squier was totally disabled due to this chronic back pain. (Tr. 633-641, 642-649.) While Dr. Maghsoudlou did not submit extensive clinical testing and treatment records in support of these medical findings and opinion, such clinical records exist, and were provided by Dr. Matt Vegari, a treating neurologist for Mr. Squier. Dr. Vegari's medical records contained test results which documented multiple medically confirmed cervical and lumbar abnormalities, including multi-level lumbar disc bulging, spinal stenosis, multi-level cervical root tenderness, arthritic conditions, carpal tunnel syndrome, muscle spasms, tendonitis, and rotator cuff injuries. (Tr. 600-626.)
In the face of this medical evidence from various treating sources, two of whom opined that Squier suffered a functional disability due to the back of neck injuries, the Commissioner points to no countervailing medical opinion evidence suggesting that Squier can work. Indeed, it is undisputed that: "The record does not contain an assessment of the claimant's physical limitations from a state agency medical consultant." (Tr. 27.) Thus, the Administrative Law Judge was provided no medical evidence contradicting the opinions of these various treating sources. Nonetheless, notwithstanding the lack of any medical opinion evidence supporting the contention that Squier could perform gainful activity on a sustained basis, the ALJ rejected these treating source opinions, concluded that Squier retained the capacity to perform light work, and denied Squier's application for disability benefits. (Tr. 18-29.)
For the reasons set forth below, we conclude that this decision should be remanded to the Commissioner for further consideration of the existing medical evidence, and further development of the medical record, if necessary.
II. STATEMENT OF FACTS AND OF THE CASE
A. MEDICAL BACKGROUND
On July 13, 2013, Gerald Squier applied for Social Security Disability benefits, alleging that he had been disabled since April 8, 2011. (Tr. 161-167.) Squier was 48 years old at the time he alleged that his back, shoulder and neck pain, along with other complicating medical conditions left him disabled. (Tr. 44, 161.)
In fact, significant evidence in the record of these proceedings documented that Squier suffered from a series of severe and painful neck, shoulder and back conditions. Thus in the Spring of 2011 Squier was seen, tested and treated by a neurologist, Dr. Matt Vegari, whose clinical findings documented a series of serious spinal problems for Squier.
When Squier was first seen by Dr. Vegari on April 15, 2011, he was complaining of chronic neck and low back pain. Squier's 2010 lumbar and cervical spine MRIs showed multi-level lumbar disc bulging with chronic arthritic changes and facet hypertrophy, and cervical spine disc herniation with spinal canal stenosis at C5-6. Squier presented with low back pain radiating to his right lower extremity and neck pain radiating to his bilateral upper extremities. Neurological review of systems was positive for episodes of passing out (cardiology was unable to find the cause) and memory loss with episodes of staring/zoning out. (Tr. 602.)
On examination, Squier appeared to be "in a chronic degree of pain and discomfort." There was cervical and trapezius muscle spasm, limitation of neck movement to both horizontal planes, facet tenderness at C4-5 and C5-6, and multilevel cervical root tenderness along with lumbosacral paraspinal muscle spasm, lower lumbar facet tenderness, and sacroiliac joint tenderness bilaterally. Neurological examination revealed reduced grip strength, bilaterally diminished ankle jerks, and bilaterally positive Tinel, Phalen, and crossed adductor signs. Based upon this examination and testing Dr. Vegari's assessment was that Squier was experiencing: (1) Displacement of lumbar intervertebral disc without myelopathy; (2) Displacement of cervical intervertebral disc without myelopathy; (3) Headache; (4) Carpal tunnel syndrome ("CTS"); (5) Cervical spinal stenosis; and, (6) Localization - related (focal)(partial) epilepsy and epileptic syndromes with complex partial seizures. (Tr. 604.)
Further diagnostic testing was ordered and on April 19, 2011, an MRI of Squier's cervical spine revealed straightening of the normal lordosis which "can be frequently found in the setting of muscular spasm." At C4-5, there was a disc bulge mildly effacing the ventral theca. At C5-6, there was a broad-based disc protrusion associated with the disc and osteophyte complex effacing the ventral theca and compressing the ventral surface of the cord across the midline. There was moderately severe right-sided neural foraminal narrowing and moderately severe central canal stenosis. (Tr. 622.)
In a follow up appointment on May 12, 2011, Dr. Vegari noted that Squier remained "in a chronic degree of pain and discomfort." Examination was unchanged from April except there was also tenderness on palpation of Plaintiff's shoulders in the anterior joint line and positive joint tenderness. Hawkin's and cross-arm tests were positive. Abduction of the shoulders was limited to 30-45° with significant point tenderness at the anterior shoulder. Squier's left shoulder was also limited in internal and external rotation. (Tr. 605-606.) As a result of these tests, rotator cuff sprain/strain was added to Squier's diagnoses.
Further testing on May 17, 19 and 20, 2011, confirmed Squier's on-going spinal, neck and shoulder impairments. As a result of this additional testing, by June 9, 2011, Dr. Vegari assessed Squier as suffering from an array of back and neck related medical impairments including: (1) Displacement of lumbar intervertebral disc without myelopathy; (2) Intervertebral cervical disc disorder with myelopathy, cervical region; (3) Headache, cervicogenic; (4) Carpal Tunnel Syndrome; (5) Rotator cuff (capsule) sprain and strain; and, (6) Syncope and collapse. (Tr. 601.)
At the same time that he was being seen by Dr. Vegari, in 2011 Squier was examined and treated by Dr. Mikhail Artamonov, a pain treatment specialist. Dr. Artamonov's clinical impressions of Squier were consistent with the test results obtained by Dr. Vegari, and included a finding of significant functional disability. Specifically, Dr. Artamonov's clinical impression was that Squier was experiencing a constellation of medical problems, including: chronic spinal pain; spinal facet joint syndrome; Secondary myofascial pain syndrome; chronic cervicalgia; chronic intermittent opioid use; and "significant functional disability." (Tr. 676.)
These medical findings, in turn, were consistent with the medical opinion of another one of Squier's treating physicians, Dr. Behzad Maghsoudlou, Squier's treating neurologist. Dr. Maghsoudlou twice submitted impairment questionnaires in in May and November of 2012 in which this physician stated that Squier was totally disabled due to this chronic back pain. (Tr. 633-641, 642-649.) According to Dr. Maghsoudlou, in an eight-hour workday, Squier could sit for a total of less than one hour and stand or walk for a total of less than one hour. Squier could only occasionally lift or carry five pounds; was markedly limited in using his upper extremities for reaching and for grasping, turning or twisting objects. He was moderately limited in performing fine manipulations; could not push, pull, kneel, bend or stoop; and was deemed unfit by the doctor for work in a full-time competitive job. (Id.)
In the face of this body of clinical and medical opinion evidence, the Commissioner obtained no countervailing medical proof relating to the nature, severity and disabling impact of Squier's back and neck injuries. Quite the contrary, in this case it is undisputed that: "The record does not contain an assessment of the claimant's physical limitations from a state agency medical consultant." (Tr. 27.)
It was against this clinical backdrop that Squier's disability claim came to be considered by ...