Redd v. Kijakazi
| Decision Date | 04 February 2022 |
| Docket Number | 4:20-cv-000880-MTS |
| Parties | JOHN REDD, Plaintiff, v. KILOLO KIJAKAZI, acting commissioner of the Social Security Administration, Defendant. |
| Court | U.S. District Court — Eastern District of Missouri |
This matter is before the Court for review of the final decision of Defendant, the acting Commissioner of Social Security denying the application of John Redd (“Plaintiff”) for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C §§ 401 et seq. (the “Act”).
On August 11, 2016, Plaintiff filed an application for disability insurance benefits under the Act with an alleged onset date of May 19, 2015. (Tr. 80, 261-62, 279). After Plaintiff's application was denied on initial consideration, he requested a hearing from an Administrative Law Judge (“ALJ”). (Tr. 10, 197-200, 201-202). Plaintiff and his counsel appeared for an in-person hearing before the ALJ on March 20, 2018. (Tr. 100-43). In a decision dated August 17, 2018, the ALJ concluded Plaintiff was not disabled under the Act. (Tr. 7-25). The Appeals Council denied Plaintiff's request for review on May 12, 2020. (Tr. 1-7). Accordingly, the ALJ's decision stands as the Commissioner's final decision.[1]
Plaintiff was born in 1970, and he alleged he became disabled beginning May 19, 2015, at age 45, due to lower back issues, leg nerve damage, diabetes, arthritis in his knee, neuropathy in his feet, and memory loss. (Tr. 279). Plaintiff has a college education and past work as an instructor in the U.S. Army, a corrections officer, a jailer for a sheriff, a small product assembler, and a house parent. (Tr. 288-98).
In an August 2016 Function Report, (Tr. 299-313), Plaintiff indicated his medical conditions affected lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, hearing, stair climbing, and using his hands. Additionally, these conditions kept him from being active, cutting firewood, handling water, washing dishes, woodworking, mowing the lawn, cooking, sitting too long, standing too long, walking too far, and driving long distances. He wore a brace for his knee and used a cane and a hearing aid. Plaintiff indicated his medical conditions also affected memory, completing tasks, concentration, understanding, and getting along with others. He could pay attention for about 10 minutes; he did not do well with spoken instructions because he gets lost and frustrated. Plaintiff indicated he did not handle stress well and that he would get frustrated and angry. Plaintiff stated he could not stop seeing things from his military experiences, PTSD; had bad dreams; did not want to do anything or go anywhere; could not remember things; and could not be around large crowds.
Plaintiff indicated he was in a lot of pain; sometimes he cried from the pain in his back and legs. He also had to walk on the side of his foot, which caused knee pain, hip pain, and back pain. The pain also interfered with his sleep because he would wake up in the middle of the night in pain and needed to move around. Plaintiff indicated his medications had many side effects, especially making him sleepy. Plaintiff stated there was not much he could do; he used to be active and now could do nothing. Plaintiff indicated his day consisted of sitting watching TV; taking a nap or lying in the bed, because it helps with his back-pain; walking to the living room; sitting; letting the dogs out; taking a nap; making dinner; watching TV; and going to bed.
Plaintiff indicated his basic living is poor. Regarding dressing, Plaintiff had to take his time; as to bathing, he endorsed difficulty washing his hair and his wife had to check the water to make sure it is not too hot;, he endorsed difficulty wiping after using the toilet. Plaintiff reported his wife had to remind him to take medications, as well as help with his medications so he did not take too much; when his wife worked late, Plaintiff had to have medications all in a row with notes. Plaintiff could feed himself but did not cook and only heated up leftovers. Plaintiff indicated he could drive a car, but his wife did most of the driving. His wife also did the shopping, indicating he could not do it for long or very much. If he did walk, Plaintiff used a cane or a cart while in a store.
The relevant time period for consideration of Plaintiff's claim is from May 19, 2015, the alleged onset date, until December 31, 2016, the date his insured status expired. This point is not contested.
Plaintiff's knee pain began after a fall in July 2014. A February 2015 x-ray of the left knee was considered unremarkable. (Tr. 409-10). In May 2015, Plaintiff was diagnosed with iliotibial band tendonitis. (Tr. 490). That month, Plaintiff reported pain had not resolved with conservative care; he had tried therapy, including a steroid injection, and taking anti-inflammatories, but his doctor had taken him off the anti-inflammatories secondary to esophageal stricture. (Tr. 706).
Plaintiff noted pain limits him from doing a lot of things, and he wears a brace, which helps quite a bit, but he reports it catching. During the exam Plaintiff reported pain and showed tenderness along the IT band insertion and LCL. The provider noted his ligaments were very stable, and that Plaintiff showed no joint line tenderness, no medical pain with palpation, and no acute distress. A previous MRI was reviewed, and the clinician indicated possible degenerative medial meniscus but no acute findings. (Tr. 707). The provider recommended aggressive physical therapy and did not recommend an arthroscopy due to benign MRI findings. In October 2015, the MRI was again reviewed; no tears noted or any other concerns for the causes of Plaintiff's pain. (Tr. 661-63). The provider recommended to continue conservative care and ordered physical therapy for left knee pain and strengthening. (Tr. 471).
A February 2016 x-ray of the left knee was considered unremarkable. (Tr. 402). That month, Plaintiff visited orthopedics with complaints of constant knee pain-worse pain with sitting or standing for long periods of time-and pops in the knees, described as painful. (Tr. 634). Plaintiff said his knee brace helped, but he occasionally did not wear it as he knew it can weaken his muscles. He reported tenderness, hypersensitivity, and pain with range of motion. (Tr. 635). On physical exam, it was noted Plaintiff's left knee had no effusion, erythema, or warmth, and his range of motion was at 0 to 120, stable to varus and valgus stress. The assessment was left chronic knee pain per arthroscopy, some chondromalacia. The provider recommended Plaintiff continue with the knee brace and physical therapy and told Plaintiff he would have to live with some chronic pain because he was ineligible for a total knee arthroscopic arthroplasty due to his age.
In September 2016, Plaintiff reported left knee arthritis with pain and wore a brace and walked with a cane. (Tr. 1327). In November 2016, Plaintiff reported ongoing knee pain, and x-rays were to be ordered; he was to call orthopedics if symptoms worsened. (Tr. 1290).
Doctors diagnosed Plaintiff with diabetes mellitus with neuropathy and neuroma of the right foot. (Tr. 613, 620). Plaintiff reported his painful neuroma of the right foot began in 2011. (Tr. 1272). A January 2016 x-ray of the right foot was considered “unremarkable.” (Tr. 649, 403). In April 2016, Plaintiff's chief complaints were of myoclonus, headache, and neuropathy. (Tr. 620). He reported a lot of jumping in his legs, particularly at night, which interfered with his ability to fall asleep. Plaintiff also endorsed upper extremity jerking multiple times of the day, right greater than left. (Tr. 621). An assessment noted diabetes, with painful ambulation, secondary to a foot neuroma. (Tr. 620). Plaintiff's foot had not responded to corrective inserts, shoe changes, or cortisone injections. (Tr. 1272). Plaintiff was seen in prosthetics and prescribed shoe/boots secondary to his type II diabetes mellitus with diabetic neuropathy. (Tr. 463).
At a May 2016 follow-up examination related to his diabetes, Plaintiff reported a small eruption on his right forearm and no other new problems. (Tr. 614). Plaintiff's objective physical status was “unremarkable, ” despite a very high hemoglobin A1C level, indicative of non-compliance with his prescribed diet. (Tr. 615).
In August 2016, Plaintiff presented with a hemoglobin A1C of 9.1 and he complained of muscle jerks, which a provider stated could be related to uncontrolled diabetes. (Tr. 578). He complained of jerking motions on bilateral sides, primarily at night; they involved the hands, arms, legs, and feet and may have awoken him at night. (Tr. 575). In September 2016, Plaintiff reported symptoms of neuropathy with numbness, burning, and tingling in his feet and legs and that it had been getting worse. (Tr. 1327). Plaintiff indicated if he was on his feet too long or sat down too long, he felt this neuropathy. The provider recommended dietary changes, exercise, and maintaining his glucose, blood sugar, and A1C at appropriate levels. (Tr. 1329).
In December 2016, Plaintiff's reported an HbA1c of 8.7 which was down from 9.1, but still at a high-level attributed to missing doses of medication. (Tr. 1284). The assessment at that time was Plaintiff was clinically doing fine but having foot pain. (Tr. 1285). The provider noted Plaintiff's diagnoses of uncontrolled type II diabetes mellitus, complicated by DKD on ACEI; obesity; hyperlipidemia; and chronic pain. (Tr. 1285). That same month, ...
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