United States District Court, M.D. Pennsylvania
RICHARD P. CONABOY, UNITED STATES DISTRICT JUDGE
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.
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.
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.)
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.
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.
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.
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.
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.
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.)
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.)
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.)
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.
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
(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
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.
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.
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.)
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.)
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.)
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.
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.)
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.)
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