Tuttle v. Saul
| Decision Date | 20 May 2021 |
| Docket Number | Case No. 3:20-cv-30064-KAR |
| Parties | MATTHEW J. TUTTLE, 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 JUDGMENT ON THE PLEADINGS AND DEFENDANT'S MOTION TO AFFIRM THE COMMISSIONER'S DECISION
Matthew J. Tuttle ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g) seeking review of a final decision of the Commissioner of Social Security ("Commissioner") denying his application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act (the "Act"), 42 U.S.C. § 401 et seq. Plaintiff applied for DIB on May 30, 2017 alleging a September 1, 2015 onset of disability due to chronic regional pain syndrome ("CRPS") of his dominant left hand and depression (Administrative Record "A.R." at 42, 182). After a hearing, the Administrative Law Judge ("ALJ") found that Plaintiff was not disabled from September 1, 2015 through February 22, 2019, the date of the decision, and denied his application for DIB (A.R. at 42-59). The Appeals Council denied review on March 3, 2020 (A.R. at 1-7) and, thus, Plaintiff is entitled to judicial review. See Smith v. Berryhill, 139 S. Ct. 1765, 1772 (2019).
Plaintiff seeks remand or reversal based on his claims that the ALJ erred by failing to afford sufficient weight to Plaintiff's statements concerning the severity of his symptoms and by failing to find that depression was a severe impairment. Pending before this court are Plaintiff's motion for judgment on the pleadings (Dkt. No. 18), and the Commissioner's motion for an order affirming his decision (Dkt. No. 23). The parties have consented to this court's jurisdiction (Dkt. No. 17). See 28 U.S.C. § 636(c); Fed. R. Civ. P. 73. For the reasons discussed below, the court grants Plaintiff's motion, denies the Commissioner's motion, and remands the case for further proceedings consistent with this memorandum and order.
Plaintiff was 45 years old on the date of the hearing in January 2019 (A.R. at 142, 278). He earned a GED in 1994 (A.R. at 305). He stopped working on September 1, 2015 when he injured his dominant left hand while assembling medical equipment (A.R. at 148, 167, 305, 336).
In function reports dated July 11 and October 2, 2017, Plaintiff indicated that he was not able to use his left hand to pull on his pants and shoes, or to fasten zippers, buckles, and buttons while dressing (A.R. at 368, 374). He was not able to cut his food (A.R. at 368). The limits on his ability to use of his left hand made it difficult to wash the right side of his body, wash and brush his hair, and shave (A.R. at 368). Although he was able to prepare frozen dinners and sandwiches, he was not able to prepare meals that involved cutting, opening cans, or other actions that required the use of two hands (A.R. at 333, 368, 369). He was able to do laundry with his right hand (A.R. at 333, 369). In addition, he was able to drive and walk the dog (A.R. at 368, 370). He required assistance to shop for food (A.R. at 370).
Plaintiff first visited Steven M. Wenner, M.D., of New England Orthopedic Surgeons, Inc., on September 16, 2015 for a work-related injury to his left hand (A.R. at 481). He complained of "exceedingly severe and incapacitating" pain in his left wrist and thumb after he felt a "sudden pop" in his left thumb while turning a screw (A.R. at 481). Plaintiff was reluctant to allow Dr. Wenner to touch or manipulate his left forearm, wrist, and hand (A.R. at 481). X-rays showed no bone or joint abnormality or area of calcification (A.R. at 481). An electroneurometer ("ENM") study of the median nerve of the left wrist was normal (A.R. at 481, 616). Dr. Wenner applied a short-arm fiberglass cast, prescribed a Medrol Dosepak, and indicated that Plaintiff should remain out of work until his recheck the following week (A.R. at 481).
Dr. Wenner reexamined Plaintiff on September 25, 2015 (A.R. at 482). Plaintiff reported that the cast and the Medrol Dosepak did not relieve the "episodes of incredibly severe pain that [brought] him to his knees" (A.R. at 482). He stopped taking the Medrol Dosepak after a "couple days" because "he did not like the way it made him feel" (A.R. at 482). Plaintiff struggled to make a tight fist and fully extend the fingers of his left hand (A.R. at 482). Because Plaintiff was "generally reluctant to take medicine," he declined Dr. Wenner's suggestions of gabapentin and ibuprofen (A.R. at 482). Dr. Wenner suspected an "irritated nerve," tentatively diagnosed a mononeuropathy, recommended a consultation with a neurologist, Michael Sorrell, M.D., and indicated that Plaintiff could not return to work (A.R. at 483, 616).
Plaintiff visited Matthew Charles, D.C., at New Beginnings Chiropractic, P.C., for treatment on October 7, 2015 (A.R. at 579). Plaintiff reported that the pain in his left wrist and hand was "'unpredictable' in that it 'happen[ed] with certain movements and at times [was] notpainful (with the same movements)'" (A.R. at 579). Dr. Charles witnessed Plaintiff experiencing "severe pain" in his left hand "multiple times" during the visit (A.R. at 579). Plaintiff's apprehension about pain limited Dr. Charles' ability to test the active range of motion ("AROM") and passive range of motion of ("PROM") of Plaintiff's left hand and fingers (A.R. at 579). Dr. Charles ordered an MRI (A.R. at 580).
The October 18, 2015 MRI studies of Plaintiff's left hand and wrist showed a "[s]mall amount of soft tissue edema within the palmar soft tissues of the first digit at the level of the first M[C]P joint" of the hand (A.R. at 581, 600, 677).1 As to Plaintiff's left wrist, there was no evidence of ligament or tendon tears, but there was mild extensor carpi ulnaris tendinopathy (A.R. at 602, 679). "Scattered, small foci of increased T2 signal within the distal radius, ulna and carpal bones is a nonspecific finding that can be seen with RSD/[CRPS] and/or disuse osteopenia" (A.R. at 602, 679).2
Plaintiff began chiropractic care with Dr. Charles on October 21, 2015 and was treated on October 22, 26, 28, and November 2, 4, and 9, 2015 (A.R. at 581-84). On November 10, 2015, Dr. Charles reported that Plaintiff showed little or no improvement from the chiropractic treatments (A.R. at 585). The examination on that date revealed that flexion of Plaintiff's thumb produced the most intense pain and radial deviation and wrist extension elicited "severe pain" along the palmer surface of the hand and the lateral forearm (A.R. at 585). Dr. Charlesdiscontinued Plaintiff's chiropractic care and recommended ultrasound underwater therapy of the first metacarpal joint and the palmer surface of the left hand (A.R. at 585).
Plaintiff visited Neal C. Hadro, M.D., of Baystate Vascular Services, on November 6, 2015 (A.R. at 826). Dr. Hadro observed "a little atrophy" in Plaintiff's left forearm and "somewhat limited" ROM in his left wrist (A.R. at 826). Dr. Hadro did not think that Plaintiff's injury involved a vascular component (A.R. at 826). He recommended physical therapy and treatment by a physical medicine and rehabilitation specialist for pain relief (A.R. at 827).
Plaintiff continued to "complain bitterly" about the pain in his left hand during his November 6, 2015 visit to Dr. Wenner (A.R. at 484). The examination of Plaintiff's left elbow, forearm, wrist, and fingers revealed impaired active movement and full passive movement in the wrist and hand (A.R. at 484, 617). Dr. Wenner noted mild swelling of Plaintiff's thumb and "some evidence of vascular instability" (A.R. at 484). Because there were "enough findings to suggest a sympathetically mediated pain syndrome," Dr. Wenner referred Plaintiff to a pain management clinic for possible nerve blocks (A.R. at 484, 617). Dr. Wenner indicated that Plaintiff should not return to work until Dr. Sorrell examined him (A.R. at 484).
On November 19, 2015, Plaintiff underwent an evaluation for occupational therapy ("OT") services at Baystate Rehabilitation (A.R. at 422). Plaintiff presented with "frequent left hand 'spasms' of pain when at rest" and reported constant intense pain of 9 on a scale of 1 to 10 in his thumb, which was aggravated by movement (A.R. at 422, 423). Plaintiff's left hand was discolored, sweating abnormally, and hypersensitive (A.R. at 422). His fine and gross motor skills were impaired and his left hand and wrist displayed decreased ROM, strength, and functional status (A.R. at 423). Plaintiff attended OT sessions, which included ultrasound water therapy, on November 24, 25 and 30, 2015, December 3, 9, 11, 15, 17, 22, 24, 28, and 30, 2015,January 4, 7, 11, 14, 20, 22, 27, and 29, 2016, and February 1 and 3, 2016 (A.R. at 427, 429, 430, 433, 435, 437, 439, 443, 446, 449, 452, 453, 456-57, 460, 462, 465, 467, 469, 471, 474, 477, 478). He was discharged due to potential surgery (A.R. at 479).
On November 20, 2015, Plaintiff underwent an initial evaluation at the Baystate Health Pain Management Clinic for pain in the radial aspect of his left thumb/wrist junction (A.R. at 674). Plaintiff described the pain as "ache, pressure, stabbing, burning, cold, tingling, [and] electric," which lasted all day, every day, had averaged 8/10 in intensity during the prior week, and increased with the active use of his thumb (A.R. at 675). Pain interrupted his sleep (A.R. at 676). Although Plaintiff was able to bathe, dress, ambulate, and shop independently, he indicated that he had "'reconfigure[d] [his] whole world'" because the use of his dominant left hand was "significantly limited" by pain (A.R. at 676). Plaintiff took Aleve every other day and used marijuana daily for pain relief....
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