United States District Court, M.D. Pennsylvania
John E. Jones III
above-captioned action is one seeking review of a decision of
the Acting Commissioner of Social Security
(“Commissioner”),  denying Plaintiff Dawn
Wright's (“Wright”) application for Social
Security Disability Insurance Benefits (“DIB”),
pursuant to 42 U.S.C. § 405(g).
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. Wright met the insured status requirements of
the Social Security Act through September 30, 2015. (Tr.
filed her application for DIB under Title II of the Social
Security Act (“Act”), on May 26, 2011, alleging
disability beginning May 22, 2008. (Tr. 100). On August 14,
2011, Wright's application was initially denied by the
Bureau of Disability Determination. (Id.). Wright
filed a written request for a hearing before the
Administrative Law Judge (“ALJ”) Office of
Disability and Adjudication and Review of the Social Security
Administration, and one was held on November 7, 2012.
(Id.). On February 20, 2013, the ALJ issued a
decision denying Wright's application. (Tr. 100-12).
appealed the decision to the Appeals Council, who reviewed
the decision and entered an order on September 18, 2014,
remanding the case back to the ALJ. (Tr. 118-20). A second
hearing before the ALJ was held on January 15, 2015. (Tr.
20). At the hearing, Wright was again represented by counsel
and a vocational expert testified. (Tr. 68-81). On April 13,
2015, the ALJ issued a decision, again denying Wright's
application for DIB. (Tr. 20-36). Wright filed a request for
review before the Appeals Council on May 4, 2015 (Tr. 14-16),
which was denied. (Tr. 1-6). Thus, the ALJ's April 13,
2015 decision stood as the final decision of the
subsequently filed a complaint before this Court on September
6, 2016. (Doc. 1). After supporting and opposing briefs were
submitted (Docs. 6 and 7), the appeal became ripe for disposition.
Wright appeals the ALJ's determination on three grounds:
(1) whether the ALJ erred in failing to give controlling
weight to Wright's treating physician's opinion; (2)
whether substantial evidence supports the ALJ's
credibility evaluation; and (3) whether substantial evidence
supports the ALJ's Residual Functional Capacity
was born on July 1, 1970 and was thirty-seven years old on
the alleged disability onset date; has at least a high school
education and is able to communicate in English; and has past
relevant work experience as a production scheduler and a
price book coordinator. (Tr. 34). She alleges disability due
to rheumatoid arthritis, Raynaud's disease, fibromyalgia,
chemical sensitivities, colitis, depression, celiac sprue,
gastritis and gastroparesis. (Tr. 217, 222-24).
presented to Dr. Robert G. Sanford in 2006 for an evaluation
of widespread aches and pains. (Tr. 291). On exam, Dr.
Sanford noted tender points in the bellies of many muscles,
consistent with the trigger points of fibromyalgia.
(Id.). Dr. Sanford treated Wright's fibromyalgia
syndrome and Raynaud's phenomena through 2008 with
medication, physical therapy and counseling. (Tr. 317).
stopped treating with Dr. Sanford, and on December 15, 2010,
she began treatment with Dr. Douglas Charles. (Tr. 425). Dr.
Charles noted that Wright reported widespread pain related to
fibromyalgia. (Id.). After reviewing blood work
which showed a mildly high rheumatoid factor, Dr. Charles
referred Wright to rheumatologist Dr. Shirley Albano-Aluquin.
Albano-Aluquin of Penn State Hershey Medical Center first saw
Wright on January 14, 2011. (Tr. 448). Dr.
Albano-Aluquin's notes from that first visit provide that
Wright has chronic pain with no pain-free days and severe
fluctuations a few times a week; that in 2008, Wright started
having stiffness and pain in both ankles which is aggravated
by cold and damp weather, physical activity, and prolonged
sitting or standing; and that she has morning stiffness in
her ankles. (Tr. 448-49). On physical examination, there were
no palpable lumps and Raynaud's was not indicated. (Tr.
449). Wright's gait was normal but there was a mild
increase in her rheumatoid factor. (Id.). Dr.
Albano-Aluquin prescribed Plaquenil and Flexeril and
scheduled a follow up in four months. (Tr. 449-50).
returned to Dr. Albano-Aluquin for rheumatology follow up on
May 10, 2011. (Tr. 444). Dr. Albano-Aluquin noted that
Wright's x-rays were nonrevealing except for mild
osteoarthritis like changes; her CCP antibody was negative;
and that despite her being on hydroxychloroquine for mild
inflammatory arthritis, she noticed increased pain in her
wrists and elbows and continued to have a lot of pain in her
heels and Achilles tendon. (Id.). On physical
examination, Wright's gait was antalgic with pain in the
heel and toe walk; spine showed some paraspinal muscle
tenderness in lumbar spine; soft tissue exam showed 8 of 18
tender points; and peripheral joint exam showed bilateral
elbow joint and wrist tenderness. (Tr. 445). Dr.
Albano-Aluquin noted that Wright had increased polyarhralgia
symptoms, tendinitis symptoms of the Achilles tendon, and
plantar fascia, which is indicative of a more active or
potent inflammatory arthritis, likely from rheumatoid or
spondylarthritis. (Id.). Dr. Albano-Aluquin
prescribed a low dose of methotrexate, ordered a MRI, and
scheduled a follow up visit in three to four months.
26, 2011, the MRI findings of Wright's lower extremities
showed mild findings but no erosive changes. (Tr. 432-34). A
September 14, 2011 follow up with Dr. Albano-Aluquin revealed
that Wright was still complaining of severe pain in her neck,
wrists, and ankles. (Tr. 535). She noted that her morning
stiffness improved with the methotrexate. (Id.). On
physical examination, Wright's gait was antalgic and heel
and toe walk were painful. (Tr. 536).
January 17, 2012, Dr. Albano-Aluquin again saw Wright for her
rheumatology follow up. (Tr. 812). Dr. Albano-Aluquin's
notes provide that Wright's pain control plateaued in the
last four or five months. On physical examination,
Wright's gait was normal but she showed paraspinal muscle
tenderness and tenderness on the elbows and the hands with no
significant swelling. (Tr. 813). A May 15, 2012 appointment
indicated persistent pain in Wright's hand, elbows, feet,
and knees. (Tr. 900). On examination, Dr. Albano-Aluquin
noted a slightly stiff gate with good heel and toe walk.
(Id.). Her range of motion was good. (Id.).
Wright received injections in her knee for acute bursitis and
her methotrexate was increased. (Tr. 900-01).
returned to Dr. Albano-Aluquin on August 29, 2012. (Tr. 943).
A musculoskeletal exam showed an antalgic gait bilaterally;
spine showed diffuse paraspinal muscle and lower lumbar facet
joint tenderness; her SI joints were tender bilaterally with
some mild limitation of motion; and peripheral joints showed
tenderness of both elbows, wrists, knees, as well as ankles.
December 7, 2012 follow up with Dr. Albano-Aluquin showed a
moderate improvement of joint pains since an increase of the
methotrexate, but significantly more fatigue. (Tr. 957). Her
chronic migraine headaches also improved with medication.
(Id.). Dr. Albano-Aluquin lowered the dose of
methotrexate in order to combat the fatigue. (Id.).
Wright's follow up appointment on May 2, 2013 indicates
that her methotrexate was stopped due to liver function test
abnormalities and started Enbrel injections once a week. (Tr.
1019). However, these injections were stopped due to a
delayed-type hypersensitivity. (Id.). Wright
reported that she was doing better with the change of season
but that she experienced mild to moderate pain over her
ankles and right knee. (Id.). Wright reported that
she was taking care of her 14 month old baby and walked her
around every day. (Id.). Dr. Albano-Aluquin provided
that Wright's joints overall are not bad considering that
she is off the methotrexate and Enbrel altogether.
(Id.). To address her right knee pain flare up, Dr.
Albano-Aluquin injected the knee with Kenalog.
(Id.). Dr. Albano-Aluquin scheduled a follow up in
five months and did not prescribe any medication.
Wright's October 4, 2013 appointment, Dr. Albano-Aluquin
observed that the Kenalog injection to Wright's right
knee provided mild relief. (Tr. 1017). However, severe pain
in her small and medium joints continued, prompting Dr.
Albano-Aluquin to restart methotrexate. (Id.). Dr.
Albano-Aluquin noted that Wright's joints have improved
over the feet, especially her ankles. (Id.). On
examination, Dr. Albano-Aluquin documented an antalgic gait,
and mildly tender spine, elbow joints, knees, and ankles.
final date of treatment in the record with Dr. Albano-Aluquin
was October 14, 2014. (Tr. 1008). On physical examination,
Dr. Albano-Aluquin noted that Wright's gait was normal
and her heel and toe walk were normal. (Id.). She
had mild tenderness in the spine, subacromial bursa, pes
anserine bursa of the right knee, and mild tenderness of the
ankles and MCP's with synovial thickening.
(Id.). Wright's medications were adjusted,
otherwise, Dr. Albano-Aluquin provided that she will keep the
regimen the same as it has afforded a lot of relief and
enabled Wright to perform all her activities and function.
Residual Functional Capacity Assessments
January 6, 2011, Dr. Douglas Charles, Wright's primary
care doctor, examined her and opined that she was able to
provide childcare services. (Tr. 406). His physical
examination of Wright revealed no tenderness in the bilateral
upper and lower extremities, no instability, and full range
of motion. (Tr. 420).
22, 2011, Dr. David Mize, Wright's gastroenterologist,
completed a medical source statement with regard to her
ability to perform work related physical activities. (Tr.
471-72). Dr. Mize opined that she had no functional