Stephens v. Colvin
| Decision Date | 13 March 2017 |
| Docket Number | CASE NO. 1:15-cv-02029-YK-GBC |
| Parties | STEVE STEPHENS, Plaintiff, v. CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY, Defendant. |
| Court | U.S. District Court — Middle District of Pennsylvania |
(JUDGE KANE)
(MAGISTRATE JUDGE COHN)
REPORT AND RECOMMENDATION TO DENY PLAINTIFF'S APPEAL
Docs. 1, 9, 10, 13, 20, 21
On February 27, 2012, Steve Stephens ("Plaintiff") filed as a claimant for disability benefits under Title II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1382-1383 ("Act") and Social Security Regulations, 20 C.F.R. §§ 404 et seq., 416 et seq., with a last insured date of September 30, 2014,1 and claimed a disability onset date of April 25, 2011. (Administrative Transcript (hereinafter, "Tr."), 13).
After the claim was denied at the initial level of administrative review, the Administrative Law Judge (ALJ) held a hearing on January 29, 2014. (Tr. 33-57). On May 15, 2014, the ALJ found that Plaintiff was not disabled within the meaning of the Act. (Tr. 10-32). Plaintiff sought review of the unfavorable decision, which the Appeals Council denied on September 14, 2015, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-5).
On October 14, 2015, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal a decision of the Commissioner of the Social Security Administration ("SSA") denying social security benefits. (Doc. 1). On December 22, 2015, the Commissioner ("Defendant") filed an answer and an administrative transcript of proceedings. (Doc. 9, 10). On February 4, 2016, Plaintiff filed a brief in support of the appeal. (Doc. 13) ("Pl. Brief")). On April 25, 2016, Defendant filed a brief in response. (Doc. 20 ("Def. Brief")). On May 2, 2016, Plaintiff filed a reply brief. (Tr. 21 ("Reply")). On November 8, 2016, the Court referred this case to the undersigned Magistrate Judge.
Plaintiff was born in August 1968 and classified by the Regulations as a younger individual at the time of the ALJ decision. (Tr. 26); 20 C.F.R. §404.1563(c). He had a GED and past work experience as a dishwasher/kitchen helper, prep cook, painter, and laborer for a cemetery and for a grocery store. (Tr. 52, 174, 183-90, 227-31). Plaintiff asserts that he is disabled due to several impairments, including low back pain, bilateral knee problems, PTSD, depression, paranoia, suicidal ideation, and violent outbursts. (Tr. 173). Earnings reports demonstrate that he earned three to four quarters of coverage from 1988 to 1999, 1992 to 1998, 2000 to 2001, 2004 to 2009.2 (Tr. 165).
On April 25, 2011, Plaintiff sought emergency room (ER) treatment for right knee and for low back pain after he was struck on the front side of his right knee by a car. (Tr. 250-58). X-rays of Plaintiff's right knee showed a small effusion with no fracture or dislocation. (Tr. 259). He was diagnosed with a right knee contusion. (Tr. 258).
On August 24, 2011, Plaintiff went to Dr. DeMuth, an orthopedic surgeon, for complaints of radicular pain from his low back to his right knee. (Tr. 274). Plaintiff reported that he was struck by a vehicle while he was walking. (Tr. 274).Plaintiff was fully ambulatory. (Tr. 274). He walked with a decided limp and exhibited positive straight leg raising on the right. (Tr. 274). He did not have signs of myelopathy. (Tr. 274). Dr. DeMuth opined that Plaintiff had posttraumatic lower back pain with right leg sciatica. (Tr. 274). An MRI of Plaintiff lumbar spine dated August 30, 2011, showed lumbar spondylosis with a mild disc protrusion at L5-S1. (Tr. 396).
On September 26, 2011, Plaintiff stated that his main problem was his right leg which, he claimed, gave way when he walked. (Tr. 273). Dr. DeMuth ordered an MRI of Plaintiff's right knee, which showed a medial meniscus tear. (Tr. 394). On November 18, 2011, Plaintiff underwent right knee arthroscopy to address a meniscus tear. (Tr. 271, 310).
On December 2, 2011, Plaintiff sought follow-up treatment and reported feeling stiff and sore, but otherwise doing well. (Tr. 270). Dr. DeMuth observed that Plaintiff moved around with a slight limp, that his range of motion was stiff, but he was ambulating, and Plaintiff reported that his left side was also bothering him due to the accident. (Tr. 270). On January 16, 2012, Plaintiff reported back pain and suicidal thoughts and depression due to his inability to work and due to the stiffness in his knees. (Tr. 269). Dr. DeMuth noted that Plaintiff seemed to have stiffness with range of motion, and "seemed to have exaggerated discomfortfor what the clinical exam suggested." (Tr. 269). Dr. DeMuth diagnosed Plaintiff with mild degenerative joint disease of the knees and depression. (Tr. 269).
On February 27, 2012, Plaintiff sought follow-up treatment for his right knee. (Tr. 268). Dr. DeMuth noted that Plaintiff seemed to have improved, had some stiffness in his leg, and that he did not find any physical reason to explain why Plaintiff's knee was locking. (Tr. 268). Dr. DeMuth opined that Plaintiff was unable to work until his knee symptoms resolve. (Tr. 268).
On April 25, 2012, Dr. DeMuth stated that Plaintiff had some residual swelling of his right knee and was mildly numb in the anterior aspect of his leg. (Tr. 282). Plaintiff could otherwise flex his knee to 120 degrees and had full extension. (Tr. 282). Dr. DeMuth stated that "all in all [Plaintiff] was doing well." (Tr. 282).
On October 19, 2012, Dr. DeMuth observed Plaintiff limping possibly due to his right knee. (Tr. 386). Dr. DeMuth noted that Plaintiff seemed a "bit hyperactive" and did not appear to be as depressed as he had been on previous visits. (Tr. 386). Dr. DeMuth noted tenderness along his right knee, but no ligament instability. (Tr. 386). Plaintiff had full range of motion of his right shoulder, as well as his right hip. (Tr. 386). There were no signs of myelopathy. (Tr. 386). X-rays of Plaintiff's right knee showed "very mild" degenerative changes. (Tr. 386). X-rays of his right shoulder were normal. (Tr. 386). Dr.DeMuth injected Plaintiff's right knee and prescribed Ultram for pain relief. (Tr. 386). On November 7, 2012, Plaintiff had a normal range of motion for the neck and normal gait. (Tr. 372-73).
On June 14, 2013, Plaintiff sought treatment for his right thumb and right knee. (Tr. 384). Dr. DeMuth observed full range of motion in the thumb with an intact neurovascular examination. (Tr. 384). Upon examination of Plaintiff's knee, Dr. DeMuth noted no ligament instability and did not note any remarkable findings. (Tr. 384). Dr. DeMuth assessed Plaintiff with chondromalacia and post-traumatic right hand pain. (Tr. 384).
On August 7, 2013, Plaintiff reported ongoing right knee pain which caused difficulty going up and down steps. (Tr. 405). Plaintiff had pain with range of motion of his right knee, but no ligament instability. (Tr. 405). Dr. DeMuth noted minor right knee effusion was noted. (Tr. 405). X-rays of Plaintiff's knees showed no obvious arthritis and x-rays of Plaintiff's lumbar spine were normal. (Tr. 405). Dr. DeMuth injected Plaintiff's right knee and advised Plaintiff to follow up in one year. (Tr. 405).
A right lower extremity Venus Doppler, performed December 20, 2011, revealed normal compressibility of the femoral and popliteal veins, indicating absence of thrombus at the knee and above. (Tr. 311).
On April 27, 2011, Plaintiff reported lower back pain, bilateral leg pain, as well as shoulder and neck pain due to a recent auto-pedestrian collision. (Tr. 312-16). It was noted that he was ambulatory, had multiple contusions, and examination of Plaintiff's neck revealed that it was non-tender and demonstrated a painless range of motion. (Tr. 313, 315-16). An x-ray of Plaintiff's lumbar spine showed mild arthritic changes with no acute fracture. (Tr. 317). An x-ray of his cervical spine showed mild degenerative changes at C5-C6 and moderate spondylosis or possible skeletal hyperostosis in his lower cervical spine. (Tr. 317).
On December 26, 2012, Plaintiff sought treatment for injury for his right thumb and right knee. (Tr. 325-36). It was noted that Plaintiff was ambulatory. (Tr. 333). Examination of Plaintiff's back revealed no costovertebral angle ("CVA") tenderness, and no vertebral tenderness. (Tr. 331). Examination of Plaintiff's neck revealed that it was non-tender and demonstrated a painless range of motion. (Tr. 331). Examination of Plaintiff's thumb revealed tenderness and mild swelling. (Tr. 331). An x-ray of Plaintiff's right thumb showed no abnormality. (Tr. 335). An x-ray of his right knee showed minimal degenerative changes. (Tr. 336).
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In a psychiatric evaluation dated December 13, 2010, Plaintiff reported that he no prior inpatient or outpatient psychiatric history. (Tr. 339). Plaintiff reported no history of suicide attempts or any psychotropic drug trials. (Tr. 339). Plaintiff reported a history of head injuries and motor vehicle accidents, and reported that he currently was not taking any medication. (Tr. 339). Plaintiff reported taking criminal justice classes for an online university and planned to transfer the credits to a local community college. (Tr. 340). Plaintiff reported twice daily cannabis use and no alcohol use or recent use of drugs other than cannabis. (Tr. 340).
Plaintiff reported that he had thought a lot about death as a result of things he had witnessed. (Tr. 338). Plaintiff reported that, at times, he thinks he sees faces in the carpet or in the concrete which are "evil." (Tr. 338). Plaintiff reported that when he was young he witnessed a man get run over by a steamroller; prior work experience which involved...
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