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Brooks v. Saul

United States District Court, E.D. Pennsylvania

December 23, 2019

ANDREW SAUL, [1] Commissioner of Social Security, Defendant.



         Clarice Brooks, (“Plaintiff”), filed this action pursuant to 42 U.S.C. § 405(g) seeking review of the Commissioner of the Social Security Administration's decision denying her claim for Disability Insurance Benefits under Title II of the Social Security Act. This matter is before me for disposition upon consent of the parties. For the reasons set forth below, Plaintiff's request for review is DENIED.


         On June 13, 2016, Plaintiff filed an application for a period of Disability Insurance Benefits under the Act. (R. 142-48). Plaintiff alleged disability since September 22, 2015, due to knee impairments and anxiety. (R. 66-68). The Social Security Administration initially denied her application on October 17, 2016. (R. 66-81, 84-88). Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”), which was held on April 27, 2018. (R. 36-65, 89- 90). Plaintiff, represented by an attorney, appeared and testified at the hearing. (R. 39-56). An impartial vocational expert (“VE”) also testified at the hearing, via telephone. (R. 56-64). On June 29, 2018, the ALJ issued a decision finding Plaintiff was not disabled and denying benefits under the Act. (R. 10-20). Plaintiff requested review of the ALJ's decision, which the Appeals Council subsequently denied on May 29, 2019, making the ALJ's decision the final decision of the Commissioner. (R. 1-5, 140-41).

         On June 28, 2019, Plaintiff filed the instant Complaint seeking judicial review of the Commissioner's decision. (Compl., ECF No. 2). On August 12, 2019, Plaintiff consented to my jurisdiction pursuant to 28 U.S.C. § 636(c). (Consent Order, ECF No. 9). Plaintiff filed her Brief in Support of Request for Review on October 21, 2019, and the Commissioner filed his Response on November 20, 2019. (Pl.'s Br., ECF No. 12; Def.'s Resp., ECF No. 13). Plaintiff also filed a Reply in further support. (Pl.'s Reply, ECF No. 14). This matter is now ripe for adjudication.


         The Court has reviewed the administrative record in its entirety, and summarizes here the evidence relevant to Plaintiff's request for review.[2]

         Plaintiff was born on October 19, 1965, and was forty-nine years old on the alleged disability date. (R. 19, 66, 142). Plaintiff does not drive, and is driven places by her husband, son, or son-in-law. (R. 42). Plaintiff had past relevant work as a school crossing guard. (R. 18, 57).

         A. Medical Evidence

         On September 22, 2015, Plaintiff tripped on cracked pavement and fell, sustaining injuries to her right ankle and left knee. (R. 39-41; 331-40). She was crossing the street while working, inverted her right ankle in a pothole, and fell on her left knee. (Id.). She treated at the Albert Einstein Medical Center emergency room for the injuries. (R. 327-62). Diagnostic imaging revealed mild soft tissue swelling, but otherwise normal alignment with no fractures. (R. 347-49). She was diagnosed with left knee injury, and instructed to apply ice, rest, take ibuprofen, and follow up with her primary care physician. (R. 338, 351).

         In October 2015, Plaintiff began treating with Dr. Francis Burke, M.D. (R. 438-82). Dr. Burke diagnosed Plaintiff with left knee contusion and right ankle sprain. (R. 460-62). Dr. Burke treated Plaintiff with medication and referred her to physical therapy. (Id.). The physical therapy treatment notes indicate Plaintiff responded well to treatment, reported improved symptoms, and made good functional gains with improved range of motion and strength. (R. 363, 369, 370, 371, 375, 376, 378, 379, 380, 382, 383, 384, 387, 388, 390, 391, 393, 395, 399, 400, 401, 402, 403, 404, 409, 411, 412, 413, 414, 415, 416, 420, 422, 425, 427, 429, 431). Plaintiff's gait improved, and she used no assistive devices for ambulation. (R. 363, 369, 408, 427).

         Dr. Burke also referred Plaintiff for an MRI, which was completed on October 28, 2015. (R. 466, 503-04, 622-24). The radiologist opined that the MRI showed tears in the anterior and posterior horns of both her lateral and medial menisci. (R. 503-04, 622-24). Plaintiff began treating with orthopedic surgeon Dr. James Tom, M.D., on November 11, 2015. (R. 499-501; see also R. 483-511). Dr. Tom reviewed the radiologist's report and diagnosed Plaintiff with complex tears of the lateral and medial menisci in her left knee. (R. 500). Plaintiff initially elected to continue with nonoperative physical therapy which improved her symptoms; however, she reported the pain was still present and ultimately decided to proceed with surgical arthroscopy of her left knee. (R. 495-99, 501).

         On February 8, 2016, Dr. Tom performed a left knee arthroscopy with limited debridement/chondroplasty. (R. 488-94). Surgery revealed that her lateral and medial menisci were intact, with “no evidence of tear despite suggestion by preoperative MRI.” (Id.). Post-operatively, Dr. Tom diagnosed Plaintiff with “[l]eft knee chondromalacia/degenerative changes.” (Id.). At follow-up appointments, Plaintiff presented with pain in her right knee exacerbated by physical therapy for her left knee, and some pain and discomfort in her left knee. (R. 483-86). On June 8, 2016, Dr. Tom noted Plaintiff presented with full range of motion, recommended she undergo physical therapy, and opined that she could return to light work duty two times a week until the end of the school year. (R. 484).

         On August 26, 2016, Plaintiff presented to consultative examiner Dr. Kathleen Mullin, M.D. (R. 592-605). Plaintiff reported a chief complaint of left knee pain resulting from her September 2015 fall. (R. 592). She indicated that she attends physical therapy three times a week, and uses a topical gel, which she reported helps. (Id.). On physical examination, Dr. Mullin noted that Plaintiff presented with a cane, and that her gait was normal both with and without the cane. (R. 594). Dr. Mullin indicated that Plaintiff had difficulty walking on her toes, but was able to walk on her heels and did not need assistance getting on or off the exam table or rising from a chair. (Id.). Dr. Mullin reported that Plaintiff presented with full range of motion in both knees, with no tenderness and negative Lachman sign. (Id.). She also noted that Plaintiff had normal neurologic findings, including no sensory deficit and 5/5 strength in her lower extremities with no muscular atrophy. (R. 594-95). Dr. Mullin diagnosed Plaintiff with “[l]eft knee pain, status post meniscal repair in 02/16 [and] [i]ntermittent right knee pain.” (R. 595). Dr. Mullin assessed Plaintiff's prognosis as “[g]ood.” (Id.).

         Dr. Mullin also completed a Medical Source Statement of Plaintiff's Ability to do Work-Related Activities (Physical). (R. 596-601). She opined that Plaintiff could frequently lift and carry up to ten pounds, occasionally lift and carry eleven to twenty pounds, and never lift and carry over twenty-one pounds. (R. 596). Dr. Mullin assessed that Plaintiff could sit, stand, and walk for eight hours total in an eight-hour workday and, at one time without interruption, sit for two hours, stand for one hour, and walk for thirty minutes. (R. 597). She also indicated that Plaintiff did not require the use of a cane to ambulate. (Id.).

         Plaintiff treated with chiropractor Marc Cohen, D.C., of Oxford Rehabilitation Center. (R. 537-76, 724-70). At her initial evaluation with Dr. Cohen, “knee - special tests” revealed negative findings in her left knee, with 5/5 myotomes in all categories. (R. 559, 557-60). Dr. Cohen diagnosed Plaintiff with left knee sprain/strain, and recommended Plaintiff undergo physical therapy. (R. 559-60). Plaintiff continued physical therapy with Dr. Cohen, who indicated that she tolerated exercises well, and that she reported decreases in pain and symptoms following therapy. (R. 537, 538, 540, 542, 543, 545, 546, 551, 552, 553, 554, 555, 556). The treatment notes show that Plaintiff occasionally presented with a single point cane, and would alternate which side depending on which knee was causing pain. (R. 552-53, 727, 730, 733, 737).

         Dr. Cohen also completed a Medical Source Statement. (R. 577-78). He assessed that in a normal workday, Plaintiff could sit for zero to two hours, and stand and walk for one hour. (R. 577). He indicated that Plaintiff could never lift and carry any weight, and could never use upper or lower extremities for pushing and pulling activity. (Id.). Dr. Cohen opined that Plaintiff would require accommodations for unscheduled walking breaks, approximately every ten to thirty minutes. (R. 578).

         Dr. Cohen referred Plaintiff for consultation with orthopedic surgeon Dr. Zohar Stark, M.D. (R. 646-55). Dr. Stark reported that Plaintiff presented with a limp to avoid using her left lower extremity, and used a cane to assist with ambulation. (R. 647). Physical examination revealed generally normal results. (Id.). Dr. Stark diagnosed Plaintiff with “[s]prain/contusion left knee[, ] status post arthroscopic surgery left knee[, and] incomplete rehabilitation of left knee.” (Id.). He assessed that “[Plaintiff] remains stable” and recommended she continue physical therapy and use NSAIDs. (Id.). Treatment notes from follow-up appointments with Dr. Stark indicate the same findings and recommendations. (R. 649, 651, 653, 655).

         Plaintiff also treated with physiatrist Dr. Amelia Tabuena, M.D. (R. 754-60). Plaintiff presented with a cane and reported left knee pain, with compensatory right knee pain. (Id.). Physical examination revealed stable gait with the cane, minimal swelling and tenderness, mild tightness of the left posterior hamstring, and 4/5 left knee flexion and extension. (R. 756, 758, 760, 762). Dr. Tabuena referred Plaintiff for an MRI, which revealed “[m]ild degenerative joint disease medially[, ] ACL sprain[, and] intact menisci.” (R. 711). Dr. Tabuena recommended Plaintiff ...

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