Robins v. Saul
| Decision Date | 25 February 2020 |
| Docket Number | Case No. 3:18-cv-30196-KAR |
| Parties | JODY A. ROBINS, Plaintiff, v. ANDREW M. SAUL, Commissioner of Social Security Administration, Defendant. |
| Court | U.S. District Court — District of Massachusetts |
MEMORANDUM AND ORDER REGARDING PLAINTIFF'S MOTION FOR REVERSAL OF THE COMMISSIONER'S DECISION AND DEFENDANT'S MOTION TO AFFIRM THE COMMISSIONER'S DECISION
Jody A. Robins ("Plaintiff") brings this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act (the "Act"), 42 U.S.C. § 401 et seq., and Supplemental Security Income ("SSI") under Title XVI of the Act, 42 U.S.C. § 1381 et seq. Plaintiff applied for DIB and SSI on October 2, 2015, alleging a January 1, 2014 onset of disability due to attention deficit hyperactivity disorder ("ADHD"), dyslexia, and bilateral hip dislocation (Administrative Record "A.R." at 14, 238, 242, 258, 262). After a hearing, the Administrative Law Judge ("ALJ") found that Plaintiff was not disabled from January 1, 2014 through October 11, 2017, the date of the decision, and denied her application for DIB and SSI (A.R. at 14-28). The Appeals Council denied review on October 15, 2018 (A.R. at 1-8) and, thus, Plaintiff is entitled to judicial review. See Smith v. Berryhill, 139 S. Ct. 1765, 1772 (2019).
Plaintiff contends that the ALJ erred by (1) failing to find that she had an impairment or combination of impairments that met or medically equaled the severity of listed impairment 1.02A; (2) determining that she had the residual functional capacity ("RFC") to perform light work with additional limitations; and (3) failing to afford sufficient weight to Plaintiff's statements concerning the severity of her symptoms. Pending before this court are Plaintiff's motion for an order reversing the Commissioner's decision (Dkt. No. 16), and the Commissioner's motion for an order affirming his decision (Dkt. No. 19). The parties have consented to this court's jurisdiction (Dkt. No. 15). See 28 U.S.C. § 636(c); Fed. R. Civ. P. 73. For the reasons stated below, the court will grant the Commissioner's motion for an order affirming the decision and deny Plaintiff's motion.
Plaintiff was 39 years old on the date of the September 13, 2017 hearing (A.R. at 35, 87). She lived with her fiancé and her two children ages six and three (A.R. at 72). Plaintiff graduated from high school and completed a computer and electronics program offered by DeVry University in New Jersey (A.R. at 53-54). In 2010, Plaintiff lived in Vermont and began working as a caretaker for her mother who had suffered a stroke (A.R. at 39-40). Plaintiff folded laundry, transported her mother to medical appointments, and shopped for food (A.R. at 40). From 2012 until late 2015 or early 2016, Plaintiff was paid to care for her mother in their home in Massachusetts (A.R. at 40-41, 43).
On December 5, 2014, Plaintiff visited her primary care physician ("PCP"), Shahnaz Rashid, M.D., at Berkshire Health Systems complaining of swelling in her right knee and pain of 5 on a scale of 1 to 10, which sometimes radiated to her right thigh and was aggravated by movement. Her range of motion was full on extension, 115 degrees on flexion, and the drawer test and ligaments test were negative. Palpation of Plaintiff's back showed "mild" tenderness of the lower lumbar spine (A.R. at 635). To treat Plaintiff's right knee, Dr. Rashid prescribed Tramadol HCL, ordered an x-ray, and referred Plaintiff to Rheumatology Professional Services ("RPS") (A.R. at 634-36).
The December 5, 2014 x-ray of Plaintiff's right knee showed a small suprapatellar effusion and mild edema within the Hoffa fat pad. There was no acute fracture, dislocation, or focal osseous lesion. The joint spaces were preserved (A.R. at 524). Dr. Rashid noted that the x-ray showed "no arthritic change" (A.R. at 626).
On December 6, 2014, Plaintiff visited the Berkshire Medical Center ("BMC") Emergency Department to have fluid drained from her right knee to relieve the pain and swelling. Her right knee was swollen but had "good range of motion." There was no erythema, warmth, or deformity, and the ligaments were stable. Plaintiff was ambulatory with a "steady gait." The emergency department physician ordered a cane and a "closed patella knee sleeve," prescribed prednisone and Motrin, and recommended that she follow up with Berkshire Orthopaedics within a week (A.R. at 509, 515-18, 1364-66).
The December 19, 2014 record of Plaintiff's visit to Dr. Rashid indicates that medication had improved Plaintiff's right knee pain and chronic back pain. The physician observed mild tenderness over Plaintiff's bilateral hips and right knee. Movement on the pole of both hips was"slightly restricted." The range of motion of Plaintiff's spine was also "slightly restricted," but there was no spine tenderness or paravertebral muscle spasm. Plaintiff was limping (A.R. at 631-33).
On February 5, 2015, Plaintiff presented to Lauren Dudley, M.D., at RPS complaining of a painful and swollen right knee and pain in her low back. Plaintiff reported that she had not taken medication for her back or seen an orthopedist for two years. Because Plaintiff had not been examined by a rheumatologist in 2005 when she experienced stiffness in her hips and back, Dr. Dudley was skeptical of Plaintiff's representation that Dartmouth Hitchcock Medical Center had diagnosed her with rheumatoid arthritis at that time. Upon examination, Plaintiff had full range of motion in her back, severely limited range of motion and severe pain in her left hip, and moderately limited range of motion and "mild" pain in her right hip. Dr. Dudley aspirated Plaintiff's right knee and injected bupivacaine and Kenalog, which alleviated the pain (A.R. at 421-25).
Plaintiff consulted James Harding, M.D., of Berkshire Orthopaedic Associates on February 20, 2015 concerning the condition of her left hip. Plaintiff described the constant and severe pain over her greater trochanter and in her groin, which radiated to her anterior and posterior thigh. The pain increased when she walked, rose from a seated position, and used stairs. Dr. Harding noted that Plaintiff was "full weightbearing" and had an antalgic gait. Upon examination, there was no tenderness over Plaintiff's sacrum, mild tenderness over her sacroiliac joints and inguinal region, and moderate tenderness over the greater trochanter. Plaintiff's left hip showed limited active range of motion with 100 degrees hip flexion, limited passive range of motion with 15 degrees hip flexion internal rotation, and 40 degrees hip flexion external rotation. An examination of Plaintiff's left knee showed normal ligaments, full and painless range ofmotion, no gross palpable tenderness, and no obvious deformities (A.R. at 469-70). An x-ray of Plaintiff's left hip indicated that arthritis had progressed since 2012. Dr. Harding administered an injection to Plaintiff's left hip on March 6, 2015 (A.R. at 523).
On March 31, 2015, Steven Nguyen, M.D., of the Pain, Diagnosis & Treatment Center of BMC ("Pain Center") treated the "severe" (9/10) pain in Plaintiff's left hip and bilateral low back and buttocks. According to Plaintiff, walking, bending, lifting, and direct pressure exacerbated the pain (A.R. at 572). Plaintiff's gait was antalgic and she favored her right side. Her left iliotibial band ("ITB") was tender to palpation, as were her bilateral paraspinal interspinous ("PSIS"), gluteus muscles, lumbar paraspinal, and lumbar facets. Bilateral straight leg raises were positive. Dr. Nguyen prescribed oxycodone and Meloxicam, recommended a bilateral sacroiliac joint injection, which had afforded relief in the past, and ordered an MRI of her lumbar spine (A.R. at 574-75).
The April 3, 2015 MRI of Plaintiff's lumbar spine showed a "tiny central disc protrusion with annular fissure [at L5-S1] which contact[ed] but d[id] not significantly deform the ventral margin of the thecal sac." There was no spinal canal or nerve root compromise. There was disc uncovering at S1-S2 due to anterolisthesis, but no disc herniation, spinal canal, or foraminal compromise. The radiologist's impression was a transitional anatomy of the lumbosacral junction with lumbarization of S1,1 left sided S1 spondylolysis, and mild levoconvex scoliosis of the lumbar spine (A.R. at 521-22).
Plaintiff received a bilateral SI joint injection on April 6, 2015 (A.R. at 501, 592-93). On April 29, 2015, Plaintiff reported a fifty percent decrease in her back and buttock pain after the injection (A.R. at 567-68).
On June 26, 2015, Plaintiff's most severe pain was in her left hip. She told Dr. Nguyen that an orthopedic surgeon recommended a left hip replacement (A.R. at 564-67).
The record of Plaintiff's May 11, 2015 visit to Dr. Dudley at RPS indicates that Plaintiff's left hip "still really bother[ed] her." The range of motion of her left hip was "severely limited" and the range of motion of her right hip was "moderately limited" with "mild pain." Her right knee was painful and swollen. Plaintiff stated that, after she received the injection in February, her knee swelled once after she went down some stairs, got stuck in a position, then popped. Dr. Dudley opined that Plaintiff's knee condition was "mechanical" (A.R. at 417-20).
On July 9, 2015 and August 25, 2015, Dr. Rashid noted that Plaintiff's right knee pain was "stable" (A.R. at 623, 626).
During Plaintiff's August 18, 2015 visit to Dr. Dudley at RPS, Plaintiff reported that her knee felt good. She only had pain in her hips and in her back. The back pain was worse in the morning and evening. Dr. Dudley observed that Plain...
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