Trenholme v. Colvin
| Decision Date | 15 January 2014 |
| Docket Number | No. 3:10-1126,3:10-1126 |
| Parties | CHRISTOPHER A. TRENHOLME, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Middle District of Tennessee |
The plaintiff filed this action pursuant to 42 U.S.C. § 405(g) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying the plaintiff's claim for Supplemental Security Income ("SSI"), as provided by the Social Security Act ("Act").
Upon review of the Administrative Record as a whole, the Court finds that the Commissioner's determination that the plaintiff is not disabled under the Act is supported by substantial evidence in the record as required by 42 U.S.C. § 405(g), and that the plaintiff's motion for judgment on the administrative record (Docket Entry No. 12) should be DENIED.
On March 27, 2007, the plaintiff applied for SSI due to mental illness with an alleged disability onset date of January 1, 2003. (Tr. 10, 41, 96, 101.) His application was denied initially and upon reconsideration. (Tr. 41-47, 52-53.) The plaintiff amended his alleged onset date to March 27, 2007 (170-71), and a hearing was held before Administrative Law Judge ("ALJ") Donald Garrison on May 12, 2009. (Tr. 20-40.) On July 28, 2009, the ALJ issued an unfavorable decision (tr. 10-19), and on September 23, 2010, the Appeals Council denied the plaintiff's request for review, thereby rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-3.)
The plaintiff was born on November 22, 1965 (tr. 96), and he was 41 years old as of his amended alleged onset date. He is not married, has a high school education, lives with his mother, and has previously worked as a machine feeder and car salesman. (Tr. 23-24.)
From February 2002 to August 2007, the plaintiff sought treatment from the Hendersonville Medical Center emergency room for various complaints including headaches, musculoskeletal pain, and complications related to diabetes. (Tr. 506-608.) He frequently presented with headaches and pain in his neck, shoulders, elbows, hips, and back, and he was treated with a variety of pain medications. (Tr. 518-19, 542-43, 545, 547, 552, 559, 567, 571-77, 580, 583, 586, 593-94, 596, 598, 602, 606-07.) X-rays taken of his right elbow (tr. 520, 523), right hip (tr. 600), and thoracic spine(tr. 582) were normal. X-rays of his left shoulder taken in 2002 and 2004 were normal (tr. 584, 597), but one taken in March 2005 revealed a "[s]mall inferior acromial spur" with "[n]o evidence of acute fracture." (Tr. 553.) An x-ray of his lower lumbar spine taken on March 14, 2002, revealed spondylosis without vertebral fracture and degenerative disc disease at L5-S1. (Tr. 600.) A May 11, 2004 lumbar spine x-ray showed "[m]oderate lumbosacral narrowing" (tr. 581), and a May 19, 2004 MRI showed a "[m]ild decrease in height of the disk space at L5 and S1" and "[m]inimal anterior bulge at L3 L4." (Tr. 578.) An MRI of the lumbar spine on September 8, 2004, showed "[e]ssentially no change from [the] prior study." (Tr. 392.)
The plaintiff was also treated at the emergency room for diabetic symptoms. (Tr. 506-07, 527-28, 536, 543, 545, 550, 555, 588.) Emergency room physicians described his diabetes as "uncontrolled" or "under poor control," and he frequently reported being noncompliant with diabetes medication, which he attributed to a lack of insurance and money to pay for the medication. (Tr. 527, 536, 543, 545, 550, 554.) In September 2005, he presented with elevated blood sugar levels and reported that he "ha[d] been dropped from Tenn Care and ha[d] not been able to get his medications." (Tr. 550.) On another occasion, he declined a prescription for insulin because he did not have money to pay for it, although the emergency room physician characterized it as a "cheap" and "affordable" alternative to the other diabetes medication he had been taking. (Tr. 545.) The doctor noted that, although the plaintiff claimed he could not afford medication, he smoked a pack of cigarettes a day and used a cell phone. Id. In February 2007, the plaintiff reported to the emergency room physician that he had not taken medication in two years and that he had self-tested his blood sugar level at "over 500." (Tr. 527, 536.) At a visit on August 4, 2007, he indicated thathe "ha[d] been taking his diabetes medicine as directed," and his glucose levels "ha[d] been running between 125 to the low 200s." (Tr. 506-07.)
From August 2004 to July 2005, the plaintiff frequently presented to Dr. Ifeanyi Obianyo with various complaints including pain in both shoulders, a swollen left knee, a lack of energy, and speech problems. (Tr. 274-405.) During this time, Dr. Obianyo diagnosed the plaintiff with cephalgia, hyperlipidemia, type II diabetes mellitus, hypertension, "excessive" weight gain, gastroesophageal reflux disease ("GERD"), insomnia, bipolar disorder, anxiety disorder, cervical and lumbar radiculopathy, and pain in his lower back, neck, left shoulder, and left knee. Id. An August 23, 2004 MRI of the plaintiff's cervical spine showed a "[s]mall disk bulge [at] C5-6 and C6-7" as well as "[m]ild central canal stenosis [at] C4-C5." (Tr. 395.) On September 8, 2004, an MRI of the plaintiff's left knee found "an area of focal partial thickness cartilage loss over the inferior margin of the lateral patellar facet associated with mild subchondral marrow edema." (Tr. 388.) This cartilage loss was characterized as a "small fissure," and the knee cartilage was "otherwise within normal limits." Id. An MRI of the plaintiff's left shoulder performed the same day revealed "mild acromioclavicular degeneration with a type II acromion" and "[m]ild tendinopathy of the distal supraspinatus and subscapularis fibers," but the rotator cuff was not torn. (Tr. 390.) On November 29, 2004, Dr. Obianyo wrote in a letter that the plaintiff suffered from "multiple medical and psychiatric problems that continue to render him disabled." (Tr. 338.)
The plaintiff saw Dr. Robert Fogolin at Middle Tennessee Orthopaedics between October 2004 and June 2005. (Tr. 261-73.) On October 12, 2004, the plaintiff presented with bilateral shoulder pain, worse in his left shoulder, and left knee pain. (Tr. 273.) Dr. Fogolin noted that the plaintiff's shoulder pain "increased with overhead activity or reaching behind his back." Id. A leftknee x-ray revealed "[m]ild degenerative changes," and a shoulder x-ray showed "[m]ild AC joint arthrosis" in the right shoulder and a "[t]ype II, possible type III acromion that may be consistent with impingement syndrome." (Tr. 270.) Dr. Fogolin diagnosed the plaintiff with "[b]ilateral shoulder impingement syndrome, left greater than right," "[l]eft knee patellofemoral arthralgia/arthrosis," obesity, non-insulin dependent diabetes mellitus, GERD, depression, anxiety, sleep apnea, and hyperlipidemia. (Tr. 271.) He administered a corticosteroid injection in the plaintiff's left shoulder, prescribed pain and anti-inflammatory medication, and recommended that the plaintiff try physical therapy, ointments, a knee brace, and over-the-counter pain medication. Id.
On November 16, 2004, Dr. Fogolin noted that these measures had not helped and recommended arthroscopic surgery on the left shoulder. (Tr. 269.) On December 17, 2004, the plaintiff underwent the procedure, which involved an arthroscopic extensive glenohumeral joint debridement, acromioplasty, and distal clavicle resection. (Tr. 268, 557-58.) On December 30, 2004, Dr. Steve Larson conducted a post-operation examination. (Tr. 268.) The plaintiff reported that he had fallen a week earlier and "noticed more popping and cracking in his left shoulder when he move[d] his arm overhead." Id. He also reported that he had not been to physical therapy and requested additional pain medication. Id. Dr. Larson detected no signs of injury from the fall, found that the plaintiff was "doing well" after surgery, referred him to physical therapy, and prescribed Lortab. Id.
On January 18, 2005, the plaintiff returned to Dr. Fogolin for a follow-up visit and again reported that he had fallen on his shoulder, mildly exacerbating his pain.2 (Tr. 267.) Dr. Fogolin prescribed medication for pain and inflammation and advised the plaintiff to continue physical therapy. Id. On March 18, 2005, the plaintiff reported that he had fallen again and re-injured his shoulder. Id. Dr. Fogolin expressed concern that "[f]or some reason [the plaintiff] continues to injure his left shoulder," and he noted that the plaintiff had passive full range of motion but did "not put hardly any effort into his [active] range of motion." (Tr. 266-67.) Dr. Fogolin observed the plaintiff taking his coat off and noted that he "definitely moved the left shoulder much better when he thought he was not being watched." (Tr. 266.) Dr. Fogolin characterized this behavior as "strange and possible [sic] consistent with symptom magnification or malingering." Id. Dr. Fogolin concluded that, (Tr. 265.) Dr. Fogolin opined that the plaintiff "simply need[ed] to work on getting his range of motion" in his shoulder. Id. Dr. Fogolin administered a corticosteroid injection in the plaintiff's knee, suggested that he use a brace, and advised him that losing weight would "help him dramatically." Id.
A left shoulder MRI taken on March 29, 2005, found tendinopathy in the plaintiff's biceps, supraspinatus, and infraspinatus muscles as well as "[c]ystic change within the humeral head...
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