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Showalter v. Berryhill

United States District Court, M.D. Pennsylvania

August 24, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Pending before the Court is Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act and Supplemental Security Income (“SSI”) under Title XVI. (Doc. 1.) Plaintiff filed applications for benefits on September 11, 2013, alleging a disability onset date of May 26, 2010. (R. 18.) After he appealed the initial denial of the claims, a hearing was held on July 14, 2015, and Administrative Law Judge (“ALJ”) Randy Riley issued his Decision on July 24, 2015, concluding that Plaintiff had not been under a disability during the relevant time period. (R. 26.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on November 8, 2016. (R. 1-6.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on January 5, 2017. (Doc. 1.) He asserts in his supporting brief that the Acting Commissioner's determination should be reversed or remanded for the following reasons: 1) the RFC assessment was inadequate because it failed to include all of Plaintiff's limitations of record; 2) the ALJ erred by giving Plaintiff's treating physician's opinions limited weight; and 3) the ALJ erred by relying on the absence of aggressive medical treatment to discount Plaintiff's credibility. (Doc. 13 at 3.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly denied.

         I. Background

         Plaintiff was born on September 11, 1966, and was forty-three years old on the alleged disability onset date. (R. 24.) He has a high school education and past relevant work as a maintenance technician. (R. 24.)

         A. Medical Evidence

         In February 2010, Plaintiff was seen by Joseph E. Alhadeff, M.D., of Orthopaedic and Spine Specialists at the request of Mark Catterall, M.D., for right elbow pain, stiffness, and swelling. (R. 252-54.) Dr. Alhadeff diagnosed bursitis, gout, and possible tendonitis and injected Plaintiff's elbow at the first visit. (R. 254.) At his follow-up visit, Dr. Alhadeff recorded that the elbow was much better and he encouraged Plaintiff to do exercises to prevent recurrence. (R. 252.)

         Plaintiff was seen at Manchester Family Medicine on July 30, 2010, for complaints of back pain and lumbar stiffness in the morning for the preceding two months. (R. 273.) Notes indicate that x-ray and MRI were done at Dr. Catterall's office. (Id.) Notes were signed by Jeffrey Perry, D.O., who specializes in family practice.[1]

         On August 6, 2010, Plaintiff was seen by K. Nicholas Pandelidis, M.D., of Orthopaedic and Spine Specialists at the request of Jeffrey Perry, D.O., because of low back problems. (R. 250.) By history, Dr. Pandelidis recorded that Plaintiff

twisted his back at work about 8 weeks ago. He apparently was on some type of motor scooter and lost control of the scooter and twisted his back. He has been having an aching pain in the mid to upper lumbar region. The pain is worse with activities. The pain does improve with rest. He had a course of therapy without much improvement. He is not using any medications currently. He has been working 4 hour[] shifts instead of the usual 12 hour shifts.

(Id.) Physical examination findings were normal except back examination showed moderately decreased range of motion and mild upper lumbar tenderness. (Id.) X-rays showed moderate upper lumbar degenerative changes with no evidence of a destructive process or fracture. (Id.) Dr. Pandelidis diagnosed work-related back pain with irritation of pre-existing underlying degeneration. (Id.) Dr. Pandelidis found “no evidence that he has sustained an injury that should leave him with any permanent impairment or dysfunction.” (Id.) His treatment plan was symptom care and an exercise regimen. (Id.) “Work Status” indicated that Plaintiff would be kept on four-hour shifts for another week and then increase the shifts to six hours with further work status assessment to be done at Plaintiff's next visit. (Id.)

         At a Central PA Rehabilitation Services Assessment on August 13, 2010, Plaintiff indicated that he had had back pain since his May 26, 2010, work injury, he had some physical therapy which helped to some degree, and the pain never really went away. (R. 262.)

         At his August 25, 2010, follow-up visit, Dr. Pandelidis noted that Plaintiff reported that his employer would not allow him to return to work. (R. 248.) Physical examination showed that Plaintiff appeared more comfortable and had better mobility, he had an element of tenderness but no spasm, he had no lower extremity weakness, hip rotation and leg raise were well tolerated, his stance was upright, and his gait was good. (Id.) Dr. Pandelidis noted that Plaintiff could return to work unrestricted the following week. (Id.)

         August 31, 2010, physical therapy notes indicate that Plaintiff had progressed with decreased pain levels and slight improvement with function. (R. 265.) Notes also show that Plaintiff was advised about the importance of exercises. (Id.)

         On September 16, 2010, Plaintiff saw Steven Triantafyliou, M.D., of Orthopaedic and Spine Specialists with complaints of midback pain. (R. 246.) Plaintiff reported that his symptoms were aggravated with activities, bending, twisting, prolonged standing, walking, car riding, coughing, and sneezing. (Id.) He also reported that rest helped his symptoms. (Id.) Plaintiff rated his pain on an average day at three out of ten with the best day being one and the worst ten. (Id.) Physical examination showed stooped posture, slow and guarded gait, some difficulty with toe and heel walking secondary to pain, tenderness of the paraspinal area of the lower thoracic and upper lumbar region, some paraspinal muscle spasm, and range of motion of the lumbar spine limited to about fifty percent of normal including limitation in flexion, bending, and rotation. (R. 246.) Dr. Triantafyliou noted that musculoskeletal exam showed good range of motion of all joints in upper and lower extremity, and no atrophy or instability and neurological exam showed that motor testing was 5/5 in all muscle groups. (R. 247.) Dr. Triantafyliou reviewed diagnostic studies: MRI scan of June 18, 2010, showed no HNP or stenosis in the lumbar spine and no other problems were noted; limited view of the thoracic spine showed some dehydration changes to T10-11 and T11-12, mild at ¶ 12-L1 with associated Schmorl's node; x-rays of the lumbar spine done on August 10, 2010, showed disc heights to be well-maintained. (Id.) He diagnosed midback pain, thoracic strain, and thoracic disc disease and recommended follow up after MRI of the thoracic region. (Id.)

         On September 20, 2010, Plaintiff had MRI of the thoracic spine which showed “[m]ultilevel intervertebral disc degeneration without evidence of significant focal canal or foraminal encroachment. No suspicious intrinsic cord lesion identified. Incidental hemangioma in T3.” (R. 255.)

         At his visit with Dr. Triantafyliou on October 5, 2010, Plaintiff continued to complain of similar back symptoms. (R. 245.) Physical examination showed generalized tenderness of the lumbar spine and thoracic spine with sensation, reflexes and motor strength normal, and provocative tests negative. (Id.) Dr. Triantafyliou commented that the September 20th MRI showed degenerative changes but no herniations, fractures, or destructive lesions. (Id.) Dr. Triantafyliou explained to Plaintiff that a mild sprain type of injury like his as well as aggravation of preexisting thoracic disc disease did not present any need for surgical intervention. (Id.) He recommended FCE (functional capacity evaluation) to assess Plaintiff's abilities and planned to see Plaintiff afterwards. (Id.)

         Plaintiff was evaluated by Jessica Haag, DPT (doctor of phsyical therapy), on October 22, 2010. (R. 258-61.) She reported that

[f]unctional testing revealed that Mr. Showalter is presently lifting in the medium category of work as demonstrated by his occasional floor to knuckle lift of 70 pounds, knuckle to shoulder lift 60 pounds, floor to shoulder lift 60 pounds, 40-foot lift and carry of 40 pounds. . . . testing was ended due to client requesting stop testing secondary to pain and fatigue.

(R. 259.) Dr. Haag found that Plaintiff could perform the following activities occasionally (up to 33% of the day): standing, walking, repetitive binding, stooping, squatting, crouching, kneeling, crawling, climbing, overhead reaching, and repetitive leg/arm movement. (R. 258.) She also found that he could frequently (34-66% of the day) sit and forward reach. (Id.) Musculokeletal Evaluation revealed the following:

Posture: Client sits with a forward flexed posture. He has notable increased thoracic spine kyphosis.
Gait: Client ambulates with a wide base of support and a forward flexed posture. Range of Motion: Lumbar spine flexion 46 degrees, extension 10 degrees, right lateral flexion 14 degrees, left later flexion 19 degrees, thoracic spine flexion 27 degrees, extension 2 degrees.
Strength: Bilateral lower extremity strength 5/5. Core muscle strength rated fair. Neurological: Client is intact to light touch throughout bilateral lower extremities.
Flexibility: Client has moderate flexibility limitations in bilateral lower extremities. Soft Tissue Assessment: Client has no areas of tenderness to palpation of the lumbar or thoracic spine and no muscle spasms.
Special Tests: Client has a negative straight leg raise and slump test bilaterally.

(R. 260.)

         At a Manchester Family Medicine checkup on November 2, 2011, it was noted that Plaintiff needed refills on medications. (R. 272.) Musculoskeletal examination findings indicate no paravertebral spasm and no tenderness. (Id.) Assessment was hypertension.

         Plaintiff again saw Dr. Triantafyliou for follow-up and FCE review on Novmeber 2, 2010. (R. 243.) Physical examination showed that Plaintiff had some generalized tenderness in the lumbar spine and some muscle spasm with no other problems noted. (Id.) Regarding his FCE, Dr. Triantafyliou reported that “[b]asically he fails in the medium work category.” (Id.) He gave Plaintiff routine back instructions, discussed activities, and noted that he planned to see Plaintiff in three months. (Id.)

         On December 21, 2010, Plaintiff was seen at Manchester Family Medicine reporting ear drainage for a week and a half. (R. 271.) No musculoskeletal or neurological physical findings were recorded. (Id.)

         At his February 15, 2011, visit with Dr. Triantafyliou, Plaintiff continued to complain of back pain, reporting that he had good days and bad days and his symptoms were aggravated with activity. (R. 242.) Dr. Triantafyliou again reported generalized tenderness in the lumbar spine and some muscle spasm and intact neurological exam. (Id.) The recorded “Plan” included that Plaintiff should “[c]ontinue on medium work restrictions” with follow-up in three to four months. (Id.)

         On February 16, 2011, Plaintiff visited Manchester Family Medicine with complaints of headaches over the preceding two months, including four days the preceding week. (R. 270.) Plaintiff noted they seemed to be associated with his back problem. (Id.) No neurological or physical examination findings were recorded. (Id.) Assessment was headache, sinusitis, TM rupture, and hypertension. (Id.)

         At a routine follow-up for hyptension on March 1, 2011, Plaintiff continued to complain of headaches. (R. 268.) No neurological or physical examination findings were recorded. (Id.) Assessment was hypertension, hyperlipidemia, and migraine. (Id.)

         Plaintiff was seen by Brian Koons, PA-C, at Orthopaedic & Spine Specialists on June 17, 2011. (R. 2440-41.) Plaintiff was seen by Mr. Koons because Dr. Triantafyliou was on vacation and Plaintiff wanted a note to be off work until his follow-up appointment with Dr. Triantafyliou. (R. 240.) Plaintiff explained that he had returned to work on light duty the previous day afer being off for a year. (Id.) He said that part of his job was cleaning cabinets close to the floor and, when he got home, he had severe pain in the lumbar spine region. (Id.) Plaintiff added that his work wanted Dr. Triantafyliou to reevaluate him. (Id.) He reported constant pain radiating down into his tailbone, he denied numbness or tingling sensations but noted nocturnal disturbances. (Id.) Physical exam showed generalized tenderness in the midline and paraspinal areas of the thoracic and lumbar spine region, with lower extremity strength and sensation intact and negative straight leg raise tests. (Id.) Mr. Koons noted that he would keep Plaintiff out of work that night and allow him to return after that with sedentary work restrictions. (R. 421.) He also noted that Plaintiff would see Dr. Triantafyliou the following week. (Id.)

         Plaintiff saw Dr. Triantafyliou on June 21, 2011. (R. 239.) Dr. Triantafyliou's physical findings were similar to earlier visits. (Id.) He reported that he gave Plaintiff ...

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