United States District Court, M.D. Pennsylvania
MEMORANDUM
RICHARD P. CONABOY, United States District Judge
Pending
before the Court is Plaintiff's appeal from the Acting
Commissioner's denial of Disability Insurance Benefits
(“DIB”) under Title II of the Social Security
Act. (Doc. 1.) Plaintiff filed an application for benefits on
September 26, 2012, alleging a disability onset date of April
19, 2008. (R. 18.) After she appealed the initial denial of
the claim, Administrative Law Judge (“ALJ”)
Elizabeth Koennecke, presiding in Syracuse, New York, held a
hearing on August 25, 2014, with Plaintiff and her attorney
appearing in Binghamton, New York. (R. 58.) ALJ Koennecke
held a supplemental hearing on December 2, 2014. (R. 82.)
With her Decision of December 5, 2014, the ALJ denied
benefits. (R. 124-43.) Plaintiff requested review of the
Decision by the Appeals Council (R. 255-57) and the Appeals
Council vacated the Decision and remanded the case for
further proceedings on February 17, 2016 (R. 144-47). The
Appeals Council specifically directed further evaluation of
Plaintiff's mental impairments, further consideration of
Plaintiff's maximum residual functional capacity
(“RFC”), and vocational expert evidence if
warranted. (See R. 40.)
On
August 22, 2016, ALJ Koennecke conducted another hearing (R.
95-107), and issued her second Decision denying benefits on
August 30, 2016 (R. 40-52). Plaintiff again requested review
which was denied by the Appeals Council on November 18, 2016.
(R. 1-6, 35-36.) With the Appeals Council denial, the
ALJ's August 30, 2016, decision became the decision of
the Acting Commissioner. (R. 1.)
Plaintiff
filed this action on January 5, 2017. (Doc. 1.) In her
supporting brief, Plaintiff asserts generally that the ALJ
committed reversible error in finding there was insufficient
evidence to establish Plaintiff could not engage in
substantial gainful activity. (Doc. 10 at 7.) After
referencing her hearing testimony, her written application,
and her husband's Third Party Function Report, Plaintiff
states that “[a]ny attempt by the Administrative Law
Judge to discredit Ms. Bidwell's testimony as
inconsistent falls short of the proper exercise of
discretionary authority. The Administrative Law Judge abused
her discretionary authority.” (Doc. 10 at 8 (citing R.
374-381, 396-403.) Plaintiff specifically avers that the
ALJ's failure to find that she does not meet Listing 1.08
is reversible error (id. at 10), the ALJ's
comments about Plaintiff's use of a cane were not
consistent with the findings of treating and examining
physicians (id. at 11-12), the ALJ demonstrated a
predisposition to deny Plaintiff's claim (id. at
12), and the ALJ's credibility findings are not supported
by evidence of record (id.). After careful review of
the record and the parties' filings, the Court concludes
this appeal is properly granted.
I.
Background
Plaintiff
was born on June 4, 1978, and was thirty-five years old on
September 30, 2013, the date last insured. (R. 50.) She has a
high school education, an associate degree as a vascular
technician, and past relevant work as a waitress,
telemarketer, and supervisor. (R. 50, 86.) At the August 25,
2014, ALJ hearing, Plaintiff explained that she was studying
for her vascular technician boards and working as a waitress
in April 2008 when she sustained the electrical burn injury
which is the basis of impairments at issue here. (R. 63-64.)
Plaintiff claimed that the following conditions limited her
ability to work: PTSD, RSD, depression, severe anxiety, and
severe nerve damage due to electrocution in her left leg and
hip. (R. 362.)
A.
Medical Evidence[1]
After
suffering the electrical burn at her house, Plaintiff was
taken to Moses Taylor Hospital in Scranton, Pennsylvania, and
transferred to the Lehigh Valley Hospital where she was
admitted for burn care on April 19, 2008. (R. 451.) The April
21, 2008, Discharge Summary indicates Plaintiff's
hospital stay was uneventful and she was discharged to home
with directions for wound care and Vicodin for pain control.
(Id.) A follow-up appointment in the Burn Recovery
Center was scheduled for April 25, 2008. (Id.) At
the April 25th visit, Plaintiff was directed to
make an appointment with a pain management doctor closer to
home to help relieve the post-injury pain. (R. 475.) She was
also prescribed Percocet for pain. (R. 497.)
Plaintiff
began seeing Thomas W. Hanlon, M.D., of Pain Care Consultants
in May 2008. (R. 620.) At the time, Plaintiff described
severe pain in the left foot with radiation to the left knee
and associated numbness and burning sensation. (Id.)
Dr. Hanlon diagnosed left foot neuropathic pain, and left
foot pain secondary to electrical burn. (R. 621.) In June
2008 Dr. Hanlon increased pain medication and in August he
planned to schedule a left lumbar sympathetic block to
address Plaintiff's continuing pain. (R. 618, 619.)
Physical examination in August showed that sensation was
positive for allodynia in the left foot, and the foot
demonstrated color change, edema, hyperhidrosis, and
antidromic radiation of pain up the leg on the left side. (R.
618.)
On May
4, 2009, Plaintiff continued to report pain despite oral
analgesics and a single lumbar sympathetic block. (R. 614.)
She was scheduled to have another block at the office visit.
(Id.) On June 24, 2009, Dr. Hanlon noted that
examination showed that neurologically Plaintiff was still
having severe pain in the left lower extremity with left foot
pain and severe problems with ambulation secondary to the
lower extremity problems. (R. 613.) Dr. Hanlon commented
that, although motor was 5/5, there was some weakness
developing in the left lower extremity secondary to lack of
use, sensation was grossly intact to light touch with the
exception of the hyperesthesia over the left foot, and deep
tendon reflexes remained absent at the left ankle. (R. 613.)
In July
2009, Dr. Hanlon recorded that there was no rush to proceed
with a possible spinal cord stimulator trial in that
Plaintiff was fairly well controlled on her analgesic
regimen. (R. 612.) In September Plaintiff reported fair pain
control. (R. 611.)
At her
January 14, 2010, visit with Dr. Hanlon, Plaintiff complained
of increased pain antidromically radiating back to the hip
which Dr. Hanlon noted was consistent with reflex sympathy
dystrophy. (R. 610.) He also noted that cold weather had
resulted in exacerbation of Plaintiff's pain.
(Id.) Examination showed limited range of motion
about the ankle secondary to pain, the foot was cold,
somewhat cyanotic and hypersensitive to touch, sensation was
intact except for the left foot, and deep tendon reflexes
were symmetric though not obtainable on the left ankle.
(Id.)
In
April 2010, Plaintiff reported that pain increased with
weight-bearing and she had moderate relief with her current
medication. (R. 608.) Dr. Hanlon's musculoskeletal exam
was normal (including a normal gait) except for left foot
allodynia and 1 edema. (R. 609.) In August, Plaintiff
complained of more hip pain which Dr. Hanlon noted to be
“secondary to gait changes secondary to RSD.” (R.
606.) Plaintiff also said she had less relief with Oxycodone.
(Id.) No abnormal musculoskeletal or neurological
findings were recorded. (R. 607.)
In May
2011, Dr. Hanlon noted that Plaintiff had failed lumbar
sympathetic block, she remained on chronic opioid medication,
and she was never able to attend physical therapy due to the
severity of her pain. (R. 600.) In June Plaintiff complained
of low back pain radiating to the left hip as well as
radicular left leg pain and numbness in the left foot with
symptoms worsening with walking. (R. 598.) Follow-up MRI of
the lumbar spine showed mild disc bulging diffusely within
the lumbar spine, and mild left foraminal narrowing at ¶
4-5 and L5-S1. (R. 622.)
At her
September 22, 2011, office visit, Plaintiff reported
radiating left foot and leg pain with cramping in the left
foot. (R. 596.) Plaintiff described the pain as severe,
throbbing, aching, and burning with associated symptoms of
numbness, foreign body sensation, and swelling.
(Id.) She also said the pain increased with
weight-bearing. (Id.)
On
January 27, 2012, Plaintiff was seen by Paul Horchos, D.O.,
of Northeastern Rehabilitation Associates. (R. 704-06.) Dr.
Horchos noted that Plaintiff's neuropathic pain had
intensified and appeared “to be moving proximally in
the leg running up to the medial aspect of the foreleg and
knee and then diagonal pattern across the knee to the lateral
aspect of the left thigh.” (R. 704.) Physical
examination findings included the following:
Her ambulation is very abnormal. She has highly antalgic
gait. She walks with her left leg out to the side and kind of
lagging behind. She leans heavily on a cane to try to take
weight off her left leg. She does not have a normal heel
strike. She does not have a normal roll over with her left
leg. Her left foot is cool to the touch but no[t] ischemic. .
. . She does have hypersensitivity of the dorsum of the foot
and has dysthesias of the sole of the foot. On the sole of
her foot she states it feels like I am slicing her with a
razor blade and on the dorsum of the foot she states it feels
as though it's pins and needles. Her ability to move her
left ankle and left toes is intact but impaired when compared
to the other side. . . . Knee and hip range of motion are
within normal limits when she's seated, but when she
stands she tends to hold them kind of in a stiff and lightly
bent pattern.
(R. 705.) Dr. Horchos's impression was reflex sympathetic
distrophy involving the left lower extremity with some
proximal progression. (Id.) He noted that
sympathetic ganglion blocks were the mainstay for treatment
of reflex sympathetic dystrophy but they did not provide
Plaintiff with much relief. (R. 706.) He recommended physical
therapy and acupuncture. (Id.)
On
January 31, 2012, Dr. Hanlon noted that Plaintiff presented
with low back pain related to her chronic left foot pain, RSD
secondary to electrical burn/injury, and subsequent
neuropathic pain and gait disturbance. (R. 590.) He reported
that sharp pain in the left knee with ambulation was
consistent with gait disturbance from RSD of the left foot.
(Id.) Dr. Hanlon noted that Plaintiff “most
assuredly has opioid tolerance” and pain continued to
trouble her although he had little to offer other than spinal
cord stimulator. (R. 592.)
On
April 20, 2012, Dr. Hanlon recorded that Plaintiff remained
on oral opioids and her pain was not completely controlled
but was acceptable. (R. 588.) He added that Plaintiff had
severe pain with ambulation and she used a cane as an
ambulatory assist. (R. 588.) Dr. Hanlon found decreased range
of motion of the left foot and ankle, 1 edema, slight
erythema, and sensory intact excpet marked allodynia in the
left foot. (Id.)
At her
August 9, 2012, visit with Dr. Hanlon, Plaintiff expressed
her desire to attempt to wean her opioid medication. (R.
587.)
Plaintiff
had a consultative examination with Sandra Pascal, D.O., on
March 24, 2013. (R. 680.) Plaintiff reported that she had
been on opioids for five years but she was not getting any
relief and had recently weaned off oxycodone. (Id.)
She rated her pain at 8/10 at the time of the visit.
(Id.) On general physical examination, Dr. Pascal
noted that Plaintiff demonstrated pain behaviors as she
ambulated and she ambulated independently with a cane in her
hand. (R. 681.) Examination of the spine showed a limited
range of motion of the lumbar spine in flexion. (R. 682.)
Examination of the extremities showed that Plaintiff had a
limited range of motion of the left hip, no range of motion
of the left hip in backward extension, difficulty moving her
toes, and her left foot was mainly in eversion. (R. 682.)
Neurological examination findings included
positive left straight leg raise. She had decreased strength
of the left lower extremity. She had an antalgic gait and was
dependent on the right lower extremity. She had difficulty
lifting her leg in order to walk without the cane. She was
unable to do toes, heels, or tandem walking. She had
decreased sensation and numbness of the left leg upon
palpation. Deep tendon reflex of the left patella was 3. The
claimant can walk only about 10 feet without her cane, ...