Matejka v. Barnhart

• Citation: 386 F.Supp.2d 198
• Decision Date: 16 September 2005
• Docket Number: No. 04-CV-6635CJS.,04-CV-6635CJS.
• Parties: Susan MATEJKA, Plaintiff, v. Jo Anne B. BARNHART, as Commissioner of the Social Security Administration, Defendant.
• Court: U.S. District Court — Western District of New York

386 F.Supp.2d 198

Susan MATEJKA, Plaintiff, v. Jo Anne B. BARNHART, as Commissioner of the Social Security Administration, Defendant.

No. 04-CV-6635CJS.

United States District Court, W.D. New York.

September 16, 2005.

William J. McDonald, Esq., Bond and McDonald P.C., Geneva, NY, for Plaintiff.

Kathleen Melhtretter, United States Attorney by Christopher V. Taffe, Asst. U.S. Atty., Rochester, NY, for Defendant.

DECISION AND ORDER

SIRAGUSA, District Judge.

I. INTRODUCTION

Before the Court are plaintiff's (# 3) and the Commissioner's (# 5) motions for judgment on the pleadings. For the reasons stated below, the Court reverses the Commissioner's decision and remands the case pursuant to the fourth sentence of 42 U.S.C. § 405(g) for a new hearing.

II. PROCEDURAL HISTORY

Plaintiff applied for Disability Insurance Benefits on July 8, 2003 alleging a disability beginning March 31, 2000. Her application was denied on August 19, 2003. She then requested a hearing before an Administrative Law Judge ("ALJ"). The hearing was held on August 4, 2004. On September 4, 2004, the ALJ issued a decision, finding that plaintiff was not disabled and denying her claim. That decision became final on December 2, 2004 when the Appeals Council denied her request for review. This action seeking review of that final decision was filed on December 30, 2004.

III. BACKGROUND

Plaintiff, who is 43 years old, is a high school graduate. (Record at 49, 71.) Her work history includes employment as a travel consultant, daycare provider, chauffeur and restoration technician (cleaner). (Record at 66, 75, 161-163). She has not worked since March 31, 2000, the alleged onset date of her disability. (Record at 161).

IV. MEDICAL HISTORY

Physical Assessment

On July 8, 1991, Dr. J.E. Nazar noted that both a magnetic resonance imaging (MRI) scan and a computerized axial tomography (CAT) scan of plaintiff's spine revealed a central herniated disc with bilateral compression of the nerve roots at L5. (R. 104). Additionally, a lumbar myelogram was positive for central disc herniation at L4-L5 with compression of the nerve root at L4-L5. (R. 97, 104).

On July 9, 1991, plaintiff underwent a lumbar laminectomy at Memorial Hospital, Inc. in Towanda, Pennsylvania. (R. 96-101). After the surgery, Dr. Nazar noted that plaintiff was completely free of pain at the hips and legs. (R. 96).

On June 5, 2003, because of low back pain, plaintiff began treating with Sean A. Stryker, M.D., who became her primary care physician. (Record at 134). Dr. Stryker observed that plaintiff stood "hunched over," noting that she had a long standing history of back pain aggravated by sitting and standing, and also observed that she walked with a mildly antalgic (distorted by pain) gait. (Record at 134). He reported that Ibuprofen, Tylenol, and Naproxen, as well as occasional chiropractic treatment, afforded plaintiff occasional relief from back pain. (R. 134). Dr. Stryker determined that she had a fair range of motion (ROM) in her back with lumbar flexion to 85 and extension to 5. His impression was chronic back pain. Dr. Stryker recommended evaluation by a pain specialist and opined that plaintiff could not be gainfully employed. (R. 134; see R. 135). Dr. Stryker suggested that Ms. Matejka apply for disability benefits despite her disinclination to "live off the state". (Record at 134).

A July 2003 lumbar x-ray showed marked disc space narrowing at L4-5, moderate narrowing at L5-S1 with low grade retrolisthesis of L3 on L4 and straightening of the lordotic curve. (Record at 128). Dr. Stryker related these findings to Ms. Matejka's spasm and pain. (Record at 133). Subsequently, a January 2004 lumbar MRI showed moderate to severe central spinal stenosis at L3-L4 and degenerative disc disease at all levels between L2 and S1. (Record at 132).

On July 25, 2003 Raja Jagtiani, M.D., of Industrial Medicine Associates, P.C., in Binghamton, New York, conducted an orthopedic consultative examination for the Division of Disability Determination. (R. 124-28). Plaintiff reported to Dr. Jagtiani that she felt good and was doing fine for at least five months following her laminectomy, after which time her back pain returned monthly, coinciding with her menstrual periods. This lasted she indicated until 1999 when she underwent a hysterectomy. (R. 124, 113-15). She also reported a history of spastic colon, which she stated was well-controlled by medication. Id. Dr. Jagtiani noted that plaintiff also had a "questionable history" of heart murmurs. (R. 125). He documented that her current medications consisted of Cenestin, Paxil, Axid AR, Tramadol, Naproxen and Amoxicillin.

Regarding her activities of daily living, plaintiff told Dr. Jagtiani that her husband performed most of the household chores, but that she cooked about twice a month, showered and dressed herself, watched television, read, cared for her pets and plants, and socialized with friends. Id.

According to Dr. Jagtiani, an x-ray of plaintiff's lumbosacral spine, taken on the date of his examination, revealed disc space narrowing, low grade retrolisthesis at L3-L4, and straightening of the lordotic curve. (R. 127; see R. 128). Dr. Jagtiani observed that plaintiff had full range of motion in her hips and ankles; that flexion/extension of her knees was to 110 on the right and to 130 on the left; that she had no muscle atrophy and no sensory abnormality; that her reflexes were physiological and equal; and that there was no joint effusion, inflammation, or instability. (R. 127).

Dr. Jagtiani's diagnosis was low back pain syndrome, cervical pain syndrome, spastic colon, and history of heart murmur. (R. 127). His prognosis was fair. The doctor assessed a mild restriction for prolonged standing and walking, a moderate restriction for squatting and kneeling, and a marked restriction for heavy lifting and carrying. Id.

On August 18, 2003, Dr. Putcha,¹ a non-examining State agency medical consultant, assessed that plaintiff could do sedentary work. (R. 129). Dr. Putcha noted plaintiff's 1991 laminectomy and that she had no neurological impairment. He reported that plaintiff had episodic back pain but was independent in ambulation and in the activities of daily living. Id.

On September 2, 2003, Dr. Stryker saw plaintiff for a follow-up visit and noted that, although no formal examination was performed on that day, his impression was chronic back pain. (R. 133). Plaintiff refused a referral to the pain clinic for epidural steroid injections. Id. He also noted, "[s]he states that simply sitting and waiting five minutes in the office here today has caused significant right leg pain. Indeed, she is sitting with her weight shifted to the left. She appears to be in pain. At times she is tearful."(Dr. Stryker's office note 9/2/03, Tr. 133).

On January 23, 2004, plaintiff underwent an MRI scan of her lumbar spine at Associated Radiologists of the Finger Lakes in Elmira Heights, New York. (R. 132; see R. 155-56). According to the radiologist, Jude Leblane, M.D., the MRI scan revealed moderate to severe central spinal stenosis at the level of L3, L4, with minimal central disk bulging at the same level but mainly degenerative changes along the posterior elements causing stenosis. Dr. Leblane also noted degenerative disc disease at all levels between L2 and S1 and opined that plaintiff was status post laminectomy at the L4-L5 level with evidence of prior diskectomy at the same level. Dr. Leblane further observed that plaintiff had normal looking distal spinal cord and cauda equina structures, that her alignment was normal, and that she had slight stenosis of foramina at the L4, L5 level. Id.

Plaintiff underwent six physical therapy sessions at Orthopedic and Sports Therapy Associates, Elmira, New York from January 28, 2004 until February 24, 2004. (R. 138-44). Upon initial evaluation, on January 28, 2004, the physical therapist, Teri Fullner, noted that plaintiff's previous functional level was within normal limits, and her general health was good. (R. 139). Plaintiff reported that she had difficulty doing household chores and prolonged activities. (R. 140). According to Ms. Fullner, plaintiff presented with decreased ROM and strength, impaired gait, decreased functionality, and increased pain. (R. 142). Ms. Fullner, after her initial assessment of plaintiff, recommended physical therapy and a home exercise program. Id. Ms. Fullner's prognosis was that plaintiff would return to her previous functional level and her rehabilitation potential was excellent. (R. 141).

On February 2, 2004, the Ms. Fullner noted that plaintiff tolerated her physical therapy well but complained of increased pain since her last visit. (R. 142). On February 4, 2004, Ms. Fullner reported that plaintiff had no new complaints, and that she tolerated the physical therapy session well. (R. 142)

On February 10, 2004 plaintiff reported at her therapy session that her back felt "a little better." (R. 142). Ms. Fullner observed that plaintiff tolerated the physical therapy session well. Id. Then, on February 11, 2004, plaintiff reported to Ms. Fullner that her back was sore, (R. 143). She stated that on a scale of zero to ten, with ten being the highest level of pain, her back pain was only between two and three. Again, Ms. Fullner observed that plaintiff tolerated the physical therapy well. Id. However, on February 18, 2004, plaintiff rated her back pain as an eight and reported that she was unable to function. (R. 143). Ms. Fullner advised plaintiff to postpone further physical therapy. Id. Plaintiff's February 20, 2004, physical therapy session was cancelled and on February 24, 2004 plaintiff was discharged from physical therapy. (R. 143).

On February 23, 2004, Dr. Stryker saw plaintiff for a follow-up visit on her complaints of depression. (Record at 130.) In addition to commenting on her depression (see infra), Dr. Stryker noted that plaintiff's had spinal stenosis. Plain...