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Sheppard v. Saul

United States District Court, E.D. Pennsylvania

October 31, 2019

ANDREW SAUL, Commissioner of Social Security[1]


          ELIZABETH T. HEY, U.S.M.J.

         Melissa Joyce Sheppard (“Plaintiff”) seeks review of the Commissioner's decision denying her claim for disability insurance benefits (“DIB”). I conclude that the decision of the Administrative Law Judge (“ALJ”) denying benefits is supported by substantial evidence and will affirm the Commissioner's decision.


         Plaintiff protectively filed for DIB on July 13, 2015, claiming that she became disabled on April 1, 2013, due to migraine headaches, chronic obstructive pulmonary disease (“COPD”), dizziness, and leg and knee pain and swelling. Tr. at 61, 119, 150.[2]The application was denied initially, id. 64-68, and Plaintiff requested an administrative hearing before an ALJ, id. at 70, which took place on May 10, 2017. Id. at 27-51. On September 19, 2017, the ALJ found that Plaintiff was not disabled. Id. at 11-21. The Appeals Council denied Plaintiff's request for review on September 25, 2018, id. at 1-3, making the ALJ's September 19, 2017 decision the final decision of the Commissioner. 20 C.F.R. § 404.981.

         Plaintiff commenced this action in federal court on October 19, 2018. Doc. 1. The matter is now fully briefed and ripe for review. Docs. 15-16.[3]


         To prove disability, a claimant must demonstrate an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment . . . which has lasted or can be expected to last for . . . not less than twelve months.” 42 U.S.C. § 423(d)(1). The Commissioner employs a five-step process, evaluating:

1. Whether the claimant is currently engaged in substantially gainful activity;
2. If not, whether the claimant has a “severe impairment” that significantly limits her physical or mental ability to perform basic work activities;
3. If so, whether based on the medical evidence, the impairment meets or equals the criteria of an impairment listed in the listing of impairments (“Listings”), 20 C.F.R. pt. 404, subpt. P, app. 1, which results in a presumption of disability;
4. If the impairment does not meet or equal the criteria for a listed impairment, whether, despite the severe impairment, the claimant has the residual functional capacity (“RFC”) to perform her past work; and
5. If the claimant cannot perform his past work, then the final step is to determine whether there is other work in the national economy that the claimant can perform.

See Zirnsak v. Colvin, 777 F.3d 607, 610 (3d Cir. 2014); see also 20 C.F.R. § 404.1520(a)(4). Plaintiff bears the burden of proof at steps one through four, while the burden shifts to the Commissioner at the fifth step to establish that the claimant is capable of performing other jobs in the local and national economies, in light of her age, education, work experience, and RFC. See Poulos v. Comm'r of Soc. Sec., 474 F.3d 88, 92 (3d Cir. 2007).

         The court's role on judicial review is to determine whether the Commissioner's decision is supported by substantial evidence. 42 U.S.C. § 405(g); Schaudeck v. Comm'r of Soc. Sec., 181 F.3d 429, 431 (3d Cir. 1999). Therefore, the issue in this case is whether there is substantial evidence to support the Commissioner's conclusions that Plaintiff is not disabled and is capable of performing jobs that exist in significant numbers in the national economy. Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion, ” and must be “more than a mere scintilla.” Zirnsak, 777 F.2d at 610 (quoting Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005)). The court has plenary review of legal issues. Schaudeck, 181 F.3d at 431.


         A. ALJ's Findings and Plaintiff's Claims

         The ALJ found that Plaintiff suffered from three severe impairments at the second step of the sequential evaluation; migraines, degenerative joint disease of the right knee, and obesity. Tr. at 13. The ALJ found that Plaintiff did not have an impairment or combination of impairments that met the Listings, id. at 15, and that Plaintiff retained the RFC to perform light work except she is limited to no climbing of ladders, ropes, or scaffolds; no kneeling or crawling; no more than occasionally performing all other postural maneuvers; no exposure to hazards such as unprotected heights or moving mechanical parts; no outdoor work; no bright or flickering lights such as those found in metal-cutting or welding; and no more than moderate noise. Id. at 16. At the fourth step of the evaluation, the ALJ found that Plaintiff could perform her past relevant work as a medical assistant. Id. at 19. In the alternative, the ALJ found at step five that there were other jobs that existed in significant numbers in the national economy that Plaintiff could perform. Id. at 20.

         Plaintiff claims that the ALJ (1) failed to properly consider the opinions of her treating neurologists, (2) mischaracterized the evidence of record, (3) erred in discrediting Plaintiff's testimony, and (4) failed to properly utilize Vocational Expert (“VE”) testimony. Doc. 15 at 5-13. Defendant responds that the ALJ properly considered the medical opinions, Plaintiff's testimony, and the VE testimony, and argues that substantial evidence supports the ALJ's decision. Doc. 16 at 6-14

         B. Summary of Medical Evidence

         The record references Plaintiff's treatment for various physical ailments, and I will summarize these first before turning to her primary complaint of migraines. Her history includes plantar fasciitis of the left foot, chest pain, vertigo, and back pain and spasm. Tr. at 228, 263, 264, 433442.[4] Plaintiff began experiencing right knee pain after a fall in August 2014. Id. at 228, 248, 377. Orthopedist George Stollsteimer, M.D., diagnosed Plaintiff with meniscal tears, a subchondral cyst, [5] subchrondal edema, [6] and degenerative joint disease of the right knee, for which she underwent arthroscopy[7] with partial meniscectomy and chondroplasty[8] on January 2, 2015. Id. at 308, 368, 377-78. After the surgery, Plaintiff underwent several injections for continued pain. Id. at 358, 360 (2/24/15 - Depo-Medrol injection), 336, 338 (5/7/15 - Orthovisc injection), 330, 333 (5/21/15 - Orthovisc injection), 319, 324, 326 (7/9/15 - lidocaine injection).[9]

         In the same fall, Plaintiff also injured her left hindfoot. Tr. at 354. An MRI revealed posterior tibial tendinitis and tenosynovitis, [10] for which Andre Pagiaro, M.D., performed Carbocaine and Depo-Medrol injection[11] on March 25, 2015. Id. at 351, 355.

         On October 23, 2015, Dr. Stollsteimer performed a right knee iliotibial band resection due to continued pain in the lateral aspect of the knee.[12] Id. at 410, 491. Two months after the surgery, Plaintiff twisted her knee and complained of increased pain in the knee. Id. at 490. In January 2016, Plaintiff again fell, landing on her right knee. Id. at 488. When she saw Dr. Stollsteimer on January 13, she was complaining of increased pain in the right knee and pain in the right ankle and left foot. Id. X-rays of the knee, ankle, and foot were unremarkable. Id. The doctor prescribed a Medrol Dosepak.[13] Id. at 489. Dr. Stollsteimer ordered an MR arthrogram to evaluate the meniscus for a re-tear or worsening arthritic symptoms, id. at 487, which revealed no evidence of a meniscal retear. Id. at 485.

         On February 25, 2016, Dr. Stollsteimer noted that Plaintiff “may be . . . dealing with the lateral patellofemoral [degenerative joint disease], ” and referred Plaintiff for further evaluation of possible patellofemoral replacement. Tr. at 483-84. Following an examination on March 24, 2016, John Avallone, D.O., planned to do a diagnostic arthroscopy. Id. at 479-80. During the surgery on June 14, 2016, Dr. Avallone found a large tear of the lateral meniscus and arthritic changes in the lateral compartment and patellofemoral joint, and performed a lateral meniscectomy and arthroscopic debridement. Id. at 475-77, 478.

         At an August 8, 2016 follow up, Plaintiff complained of pain in her right Achilles tendon. Tr. at 474. Dr. Avallone ordered an MRI of her foot and prescribed Medrol Dosepak. Id. After reviewing the MRI on September 2, 2016, Dr. Avallone diagnosed Plaintiff with chronic tendinitis of the Achilles, and noted bilateral peripheral lower extremity edema for which he recommended she consult with her cardiologist or primary care physician. Id. at 472.

         Plaintiff's primary complaint during the relevant period -- and the focus of this appeal -- involve her migraine headaches. Tr. at 31. In February 2014, Plaintiff complained to Mark Liebreich, M.D., her primary care physician, of dizziness, double vision, and headaches for the prior four weeks. Id. at 257.[14] Dr. Liebreich noted a history of pituitary adenoma.[15] Id. In September 2014, Dr. Liebreich noted that a neurosurgical evaluation concluded that the “pituitary microadenoma was not an issue and needed only yearly MRI follow-up, ” yet Plaintiff continued to suffer with vision loss, confusion, headaches, and dizziness. Id. at 252.

         Neurologist James Gaul, M.D., began treating Plaintiff on March 31, 2015. Tr. at 402. She described episodes of dizziness, sometimes causing her to fall (including a fall causing injury to her right knee). Id. “With and without the vertigo she gets recurrent headaches described as a generalized vertex pain with generalized spread, with pulsatile components and visual blurring, at times diplopia.” Id. At the time, Plaintiff's medications included Lyrica, Klonopin, Lexapro, Ambien, Dexilant, Voltaren, Percocet, and Symbicort.[16] Id. Dr. Gaul suspected migraines, prescribed a trial of Topamax, [17] and ordered cerebral electrophysiologic studies. Id. at 403. In June, Plaintiff reported that she was intolerant of and stopped Topamax, and Dr. Gaul noted that her cerebral electrophysiologic studies were normal and started her on Inderal.[18] Id. at 399. In August 2015, Plaintiff reported no improvement with Inderal for the headaches, which occurred three or four times a week, and Dr. Gaul increased the dosage of Inderal. Id. at 398. Prior to her October 13, 2015 follow up, Dr. Gaul again increased the dosage of Inderal, and at the appointment, he added imipramine[19] to her regimen. Id. at 397. In December, with no change in Plaintiff's headaches and dizziness, the doctor increased Plaintiff's imipramine. Id. at 429. On March 22, 2016, with no significant change in Plaintiff's headaches, the doctor again increased her dosage of Inderal. Id. at 428.

         On October 21, 2016, Plaintiff began treating with Rene Gomez, M.D., of Lawrenceville Neurology Center. Tr. at 500. Plaintiff reported having headaches two or more times per week that she rated an 8/10, with photophonophobia, visual disturbance, significant incapacitation and nausea/vomiting. Id. Dr. Gomez diagnosed migraines without aura, described as high frequency with significant disability, recommended a psychiatry consultation to assess her medication needs such as Effexor, and directed that she taper off imipramine, continue on Inderal, stop using oxycodone, and take Imitrex.[20]Id. at 501. At Plaintiff's November 28, 2016 follow up, Dr. Gomez noted that Plaintiff had stopped imipramine and propranolol, needed to stop Tylenol and oxycodone completely, and had not followed ...

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