Blakley v. Commissioner of Social Sec.

• Decision Date: 24 September 2009
• Docket Number: No. 08-6270.,08-6270.
• Citation: 581 F.3d 399
• Parties: Thomas H. BLAKLEY, Plaintiff-Appellant, v. COMMISSIONER OF SOCIAL SECURITY, Defendant-Appellee.
• Court: U.S. Court of Appeals — Sixth Circuit

581 F.3d 399

Thomas H. BLAKLEY, Plaintiff-Appellant, v. COMMISSIONER OF SOCIAL SECURITY, Defendant-Appellee.

No. 08-6270.

United States Court of Appeals, Sixth Circuit.

Submitted: April 23, 2009.

Decided and Filed: September 24, 2009.

ON BRIEF: Julie Anne Atkins, Atkins Law Office, Harlan, Kentucky, for Appellant. Haila Naomi Kleinman, Holly A. Grimes, Mary Ann Sloan, Social Security Administration, Office of General Counsel, Atlanta, Georgia, John S. Osborn III, Assistant United States Attorney, Lexington, Kentucky, for Appellee.

Before BATCHELDER, Chief Judge; SUHRHEINRICH and SUTTON, Circuit Judges.

OPINION

SUHRHEINRICH, Circuit Judge.

Thomas Blakley seeks review of a district court's judgment affirming the decision of an administrative law judge ("ALJ"), who denied Blakley's request for social security disability benefits. Blakley argues that the ALJ improperly rejected the opinions of his treating physicians and failed to provide reasons on the record for according them less than controlling weight. Because the ALJ failed to "give good reasons" for discounting the opinions of Blakley's treating physicians, in violation of 20 C.F.R. § 404.1527(d)(2), we REVERSE the judgment of the district court affirming the ALJ's decision and REMAND with instructions to return the claim to the Commissioner of Social Security ("Commissioner") for further proceedings consistent with this opinion.

I. Background

A. Factual Background

Born in 1959, Thomas Blakley was 47 years old at the time of the ALJ's decision. Blakley has a high-school education and worked in underground coal mines from 1979 until February 11, 2004, when he was injured while attempting to hang a six-inch pump line, which fell and hit him across his shoulder and neck.

Blakley was immediately seen at the emergency room following his accident. Thereafter, on February 19, 2004, Blakley's primary-care physician started him on a course of physical therapy. On March 17, 2004, Blakley had two MRI scans, which showed degenerative disc disease of the cervical spine and a left rotator-cuff tear. One of the MRI scans revealed disc-space changes between C5-C6 and C6-C7, a large disc osteophyte complex at C5-C6 with some flattening of the spinal cord, and large central disc osteophyte complex at C6-C7 with some flattening of the spinal cord.

Blakley began treatment with Dr. Steven Kiefer, a neurosurgeon, in April 2004. Based on Blakley's ongoing complaints of pain, Dr. Kiefer ordered a cervical myelogram and a corresponding cervical CT scan. The cervical myelogram revealed osteophytes and disc protrusions on the cervical spine. The CT scan confirmed this finding and also established that Blakley had narrowing of the neuroforamen at C5-C6, large hypertrophic boney spurs, and a mild disc bulge. It further revealed boney spurs at C6-C7.

Based on these findings, Dr. Kiefer performed an anterior cervical discectomy of the C5-C6 vertebra on July 12, 2004. Though the tests had also revealed problems with the C6-C7 vertebra, that area of Blakley's spine was not treated with surgery. Dr. Kiefer followed up with Blakley on August 6, 2004, noting that Blakley was "coming along," had normal pain from surgery, had relief of radicular symptoms in his arms, but continued to have some trouble with his hands.

Dr. Kiefer also reviewed a May 2004 electrodiagnostic study and diagnosed Blakley with carpal tunnel syndrome. Dr. Kiefer prescribed wrist splints to help with Blakley's numbness and pain, and further noted that Blakley may need carpal tunnel surgery in the future.

At the next two follow-up visits with Dr. Kiefer, Blakley complained of continued pain in his right arm with bothersome intrascapular pain. He also complained of persistent numbness in the right thumb and index finger, and numbness in the right distal arm without pain.

On February 8, 2005, Blakley was seen again by Dr. Kiefer. This time, Dr. Kiefer noted that Blakley's complaints of aches and pains related to the neck were "in excess of what I would expect at this point." Dr. Kiefer ordered an MRI of Blakley's thoracic spine, which showed degenerative disc disease at T7-T8, T8-T9, and T9-T 10 with disc protrusions. At both T7-T8 and T8-T9, the MRI showed disc material protrusion with an annular tear. On April 27, 2005, Blakley again reported to Dr. Kiefer that he continued to have intrascapular pain and left shoulder pain. Blakley also complained of upper thoracic pain with intermittent radiation into his anterior chest.

Contemporaneous with Dr. Kiefer's treatment, Blakley began treatment with Dr. Ben Kibler, an orthopedic surgeon, on May 4, 2004, for problems related to his shoulder. During Blakley's initial visit, Dr. Kibler reviewed Blakley's MRI, which showed that Blakley had a left rotator-cuff tear and bruising of the bone. On October 20, 2004, Dr. Kibler performed surgery to repair Blakley's rotator-cuff tear. Blakley's shoulder improved after surgery. By January 6, 2005, Dr. Kibler opined that Blakley would be out of work for another six weeks, after which "we can turn him loose." However, on January 24, 2005, Blakley filed an application for a period of disability and disability insurance benefits.

On February 18, 2005, Blakley reported to Dr. Kibler that his condition had worsened. He complained of soreness and tenderness and a feeling that something was catching in his shoulder. In his office notes, Dr. Kibler expressed, "I am not real sure why he has regressed."

On March 25, 2005, Blakley reported an improvement in his shoulder, but complained to Dr. Kibler of some acromioclavicular (AC) joint soreness and tenderness. On May 15, 2005, Blakley underwent an AC joint repair. On June 15, 2005, Blakley reported some soreness, but overall had better strength and range of motion after the AC joint surgery.

At the request of the Social Security Administration ("Agency"), Blakley was evaluated by Dr. Mark Burns in June 2005, shortly after Blakley's May 2005 AC joint repair. In his evaluation, Dr. Burns noted that Blakley had the ability to handle objects and had "normal gross manipulation and grip strength." Dr. Burns's examination also revealed "no clubbing cyanosis or edema ... [and] no deformities, redness or tenderness" of Blakley's extremities. Dr. Burns also noted that Blakley "states he is now wearing wrist splints bilaterally with fair relief."

Dr. Burns determined that Blakley "has ability to perform activities involving sitting, standing, moving about, lifting, carrying, handling objects, hearing, seeing, speaking, and traveling" and that his physical and orthopedic examination were "within normal limits with the exception of decreased flexion and abduction involving the left shoulder." Dr. Burns opined that Blakley "will obtain full range of motion after continued intense physical therapy."

Two consulting state agency physicians performed a records review of Blakley's evidence and claims on June 30, 2005, and September 21, 2005, respectively. They determined that Blakley could lift 50 pounds occasionally, 25 pounds frequently, and sit, stand, or walk for six hours of an eight-hour workday. The state agency physicians also found that Blakley could climb ladders, ropes, and scaffolds occasionally, but he would be limited in his ability to reach in all directions. The physicians also adopted the June 2005 opinion of Dr. Mark Burns, who determined that Blakley "has ability to perform activities involving sitting, standing, moving about, lifting, carrying, handling objects, hearing, seeing, speaking, and traveling" and that his physical and orthopedic examination were "within normal limits with the exception of decreased flexion and abduction involving the left shoulder."

On August 19, 2005, after another follow up with Blakley, Dr. Kibler noted that Blakley continued to make progress and his range of motion continued to improve. However, Blakley continued to complain of back pain, which Dr. Kibler thought may require some stabilization program. An October 18, 2005 radiography comparison showed that Blakley had some post-surgical changes of the AC joint with sclerosis on the surface of the left humeral head with possible necrosis or ostosis. On October 25, 2005, Dr. Kibler opined that most of Blakley's pain was related to his neck and back.

On December 18, 2005, Dr. Kibler restricted Blakley to "no more than 20 pounds lifting to his waist and no overhead lifting on a repetitive basis." In the report, Dr. Kibler explained that Blakley continued to have generalized problems, "some of which are related to his shoulder, a lot are related to his neck and back," all of which necessitated the restriction.

Dr. Kibler's office notes from February 16, 2006, revealed that Blakley continued to have some problems from his neck, back, and knees. Dr. Kibler also noted that Blakley showed "excellent strength in external rotation with arm down at the side" and that "[h]is x-rays do not show any abnormality of the AC joint or of the glenohumeral joint." Dr. Kibler concluded that "he may very well have some problems with the rotator cuff and AC joint but these are relatively minimal and are not giving him his functional disability."

In May 2006, at the request of Blakley's counsel, Dr. David Muffly performed an orthopedic consultative examination. In his report, Dr. Muffly reviewed Blakley's October 2005 functional capacity examination and adopted the recommendations of no overhead lifting and no more than 20 pounds from floor to waist level. Dr. Muffly noted that Blakley had normal arm strength but exhibited signs of carpal tunnel syndrome. Dr. Muffly assessed a 28% impairment to the whole body based on Blakley's cervical spine impairment, 11 % for the shoulder impairment, and 36% for the combined impairment. He also calculated a 6% impairment (3% for each hand) for carpal tunnel syndrome. In Dr. Muffly's opinion, Blakley's carpal tunnel syndrome combined with his other impairments left him "totally...