Rankin v. Saul, C/A No.: 1:19-1195-SVH

CourtUnited States District Courts. 4th Circuit. United States District Court of South Carolina
Writing for the CourtShiva V. Hodges United States Magistrate Judge
Docket NumberC/A No.: 1:19-1195-SVH
PartiesJoani Rankin, Plaintiff, v. Andrew M. Saul, Commissioner of Social Security Administration, Defendant.
Decision Date12 February 2020

This appeal from a denial of social security benefits is before the court for a final order pursuant to 28 U.S.C. § 636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of the Honorable Bruce Howe Hendricks, United States District Judge, dated April 26, 2019, referring this matter for disposition. [ECF No. 8]. The parties consented to the undersigned United States Magistrate Judge's disposition of this case, with any appeal directly to the Fourth Circuit Court of Appeals. [ECF No. 7].

Plaintiff files this appeal pursuant to 42 U.S.C. § 405(g) of the Social Security Act ("the Act") to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for disability insurance benefits ("DIB") and Supplemental Security Income("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether he applied the proper legal standards. For the reasons that follow, the court affirms the Commissioner's decision.

I. Relevant Background
A. Procedural History

On October 20, 2015, Plaintiff filed applications for DIB and SSI in which she alleged her disability began on March 21, 2013. Tr. at 102, 103, 205-06, 207-14. She subsequently amended the onset date to July 3, 2015. Tr. at 43. Her applications were denied initially and upon reconsideration. Tr. at 133-37, 144-47, 148-51. On January 31, 2018, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Flora Lester Vinson. Tr. at 39-83 (Hr'g Tr.). The ALJ issued an unfavorable decision on May 16, 2018, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 7-31. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on April 25, 2019. [ECF No. 1].

B. Plaintiff's Background and Medical History
1. Background

Plaintiff was 31 years old at the time of the hearing. Tr. at 44. She graduated high school with a diploma and obtained a certificate as a certified nursing assistant ("CNA"). Tr. at 45. Her past relevant work ("PRW") was as a tire molder, a production line assembler, and a material handler. Tr. at 75-76, 79. She alleges she has been unable to work since July 3, 2015. Tr. at 231.

2. Medical History

On April 5, 2012, magnetic resonance imaging ("MRI") of Plaintiff's lumbar spine showed disc protrusions at L4-5 and L5-S1 with mass effect on the transitioning nerve roots. Tr. at 357.

Plaintiff presented to neurosurgeon Brett C. Gunter, M.D. ("Dr. B. Gunter"), for pain in her left hip and leg and lower back on April 17, 2012. Tr. at 352. She reported pain that had occurred intermittently beginning in 2008, but had become constant in January 2012. Id. She described her pain as occurring in her back 20% of the time and in her left hip and leg 80% of the time. Id. She stated her back pain was exacerbated by sitting and lying on her left side. Id. She described her left hip and leg pain as worsened by bending, lifting, standing too long, walking, and twisting. Id. Dr. B. Gunter observed mild reduction in range of motion ("ROM") in all cardinal planes of Plaintiff's back, intact cranial nerves, 5/5 strength in the upper and lowerextremities, intact sensation to light touch, and symmetric and intact upper and lower extremity reflexes. Tr. at 352-53. He noted Plaintiff walked with a limp favoring her left leg. Id. Dr. B. Gunter reviewed results of the MRI of Plaintiff's lumbar spine and assessed lumbar spondylosis with an L5 radiculopathy. Tr. at 353. He prescribed Norco, recommended a lumbar epidural steroid injection ("ESI"), and indicated Plaintiff would likely require surgery if the ESI provided no relief. Id. Steven B. Storick, M.D. ("Dr. Storick"), administered a lumbar ESI on April 25, 2012. Tr. at 354.

On May 8, 2012, Plaintiff reported little benefit from the lumbar ESI. Tr. at 350. Dr. B. Gunter noted Plaintiff's left hip and leg pain remained severe despite conservative management. Id. He observed reduced ROM in Plaintiff's back and reduced sensory function over the posterior aspect of her lower extremities. Id. He advised Plaintiff of treatment options, and Plaintiff opted to proceed with surgery. Id.

Dr. B. Gunter performed minimally-invasive lumbar discectomy at Plaintiff's left L4-5 level on May 24, 2012. Tr. at 337-38. He identified and removed a large, contained, left L4-5 herniated disc without difficulty and accomplished good decompression without spinal fluid leak. Tr. at 338.

On June 19, 2012, Plaintiff reported pain in her right hip and heaviness in her right arm, but indicated her left-sided symptoms had improved. Tr. at 349. Dr. B. Gunter observed reduced ROM in Plaintiff'sback, a well-healed surgical scar over the lumbar spine, and 5/5 strength throughout her lower extremities. Id. He indicated he was concerned about Plaintiff's new right upper extremity symptoms, but noted they could be transient. Id. He referred Plaintiff for lumbar physical therapy with development of a home exercise program. Id.

Plaintiff presented to physical therapist Shannon B. Berrian ("PT Berrian"), for an initial physical therapy evaluation on June 21, 2012. Tr. at 340. She reported she was no longer experiencing pain in her left lower extremity, but continued to feel right-sided back pain. Id. She described her pain as constant and rated it as a five-to-six of 10. Id. She endorsed difficulty sleeping because of pain. Id. PT Berrian noted decreased lumbar lordosis, normal gait, 5/5 knee and ankle strength, 4/5 hip strength, intact sensation to light touch in the bilateral lower extremities, and tenderness to palpation at L4-5. Tr. at 341. Plaintiff endorsed pain and tightness with forward flexion and back pain with trunk extension. Id. PT Berrian expected Plaintiff would "benefit from physical therapy to improve functional strength and mobility and decrease complaints of pain." Id. She indicated Plaintiff should follow up three times a week for four weeks. Id. PT Berrian discharged Plaintiff from physical therapy on July 13, 2012, based on inconsistent attendance interfering with goal accomplishment. Tr. at 339. She noted Plaintiff had"[n]o-showed" for three consecutive appointments and had missed six total appointments. Id.

On July 31, 2012, Plaintiff reported mild pain in her lower back and greater pain on her right side. Tr. at 348. She indicated her strength remained normal. Id. Dr. B. Gunter observed reduced ROM in Plaintiff's back and 5/5 strength throughout her lower extremities. Id. He stated Plaintiff was "much better and may return to work full time and full duty at completion of her two weeks of lumbar physical therapy and home exercise program." Id.

Plaintiff presented to Gurdon Counts, M.D. ("Dr. Counts"), with back pain on March 11, 2013. Tr. at 406. She described pain in her buttocks and thighs, but denied joint complaints, joint erythema, joint swelling, myalgias, and stiffness. Id. She indicated her back pain was interfering with her abilities to sleep and work. Id. Dr. Counts observed an overall benign spine with some tenderness in the lumbar area, but good posture, normal straight-leg raise, and full flexion, extension, lateral bending, and rotation. Id. He assessed degenerative lumbar/lumbosacral intervertebral disc and prescribed Diclofenac Sodium 75 mg and Ultram 50 mg. Id.

On March 26, 2013, Plaintiff sought clarification from Dr. Counts as to her ability to perform work activity. Tr. at 403. Dr. Counts noted Plaintiff's job required "[s]he constantly lift[] 10 to 20 lb bobbins and drive[] fork lift andother machinery." Id. Plaintiff reported the vibrations of the machinery caused her back pain. Id. She stated she would lie down after work to relieve discomfort. Id. Dr. Counts noted that Plaintiff's neurosurgeon had released her to full duty. Id. He provided a note stating Plaintiff was "unable to continue the present pace of work," but explained he did not consider "assessing her competence to continue [the] job" to be within his area of expertise. Id.

On April 23, 2013, Plaintiff endorsed intermittent pain in her lower back and constant pain in her bilateral buttocks and hips. Tr. at 346. Dr. B. Gunter observed the following: mild reduction of ROM in all cardinal planes of Plaintiff's back; 5/5 strength in her bilateral upper and lower extremities; mild reduction in light touch sensation over the right posterior and anterior thigh, anterolateral lower leg, and dorsum of the right foot; and symmetric and intact upper and lower extremity reflexes. Tr. at 346-47. He recommended an MRI of the lumbar spine to evaluate for nerve root compression and lumbar x-rays to evaluate for instability. Tr. at 347. He prescribed Norco for pain and indicated Plaintiff should remain out of work. Id.

On June 25, 2013, Plaintiff complained of back pain and consulted with Dr. Counts about medical leave from work and obtaining a new MRI. Tr. at 398. She endorsed back pain and leg pain, primarily on the right. Tr. at 399.Dr. Counts noted tenderness in Plaintiff's lumbar spine, but full flexion, extension, rotation, and lateral bending and normal straight-leg raise. Id. He provided a "[n]ote for light duty X 6 mo. No lifting [or] bending." Id.

Plaintiff presented to Dr. Counts for medication refills on January 8, 2014. Tr. at 394. She complained of stiffness and pain in her low back and hips. Id. Dr. Counts noted tenderness in Plaintiff's lumbar spine, but full extension, lateral bending, and rotation and normal straight leg raise. Id. He assessed degeneration of the...

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