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Wright v. Colvin

United States District Court, M.D. Pennsylvania

May 2, 2017

DAWN WRIGHT, Plaintiff,


          Hon. John E. Jones III

         The above-captioned action is one seeking review of a decision of the Acting Commissioner of Social Security (“Commissioner”), [1] denying Plaintiff Dawn Wright's (“Wright”) application for Social Security Disability Insurance Benefits (“DIB”), pursuant to 42 U.S.C. § 405(g).

         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. Wright met the insured status requirements of the Social Security Act through September 30, 2015. (Tr. 22).[2]

         Wright 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).

         Wright 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 Commissioner.

         Wright 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[3] 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 (“RFC”) assessment.

         I. FACTS

         Wright 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).

         A. Wright's Impairments

         Wright 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).

         Wright 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. (Tr. 422-23).

         Dr. 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).

         Wright 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. (Id.).

         On May 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).

         On 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).

         Wright 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. (Tr. 943).

         A 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. (Id.).

         At 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. (Id.).

         Wright's 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. (Tr. 1009).

         B. Residual Functional Capacity Assessments

         On 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).

         On June 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 ...

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