United States District Court, E.D. Pennsylvania
A. SITARSKI UNITED STATES MAGISTRATE JUDGE
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.
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,
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.
Court has reviewed the administrative record in its entirety,
and summarizes here the evidence relevant to Plaintiff's
request for review.
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).
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).
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).
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).
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).
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
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.).
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).
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).
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).
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 ...