Walter v. Saul

• Decision Date: 20 April 2020
• Docket Number: Civil No. 1:19-CV-769
• Parties: DALE WALTER, Plaintiff v. ANDREW SAUL, Commissioner of Social Security, Defendant
• Court: U.S. District Court — Middle District of Pennsylvania

DALE WALTER, Plaintiff v. ANDREW SAUL, Commissioner of Social Security,¹ Defendant

Civil No. 1:19-CV-769

UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

April 20, 2020

(Magistrate Judge Carlson)

MEMORANDUM OPINION

I. Introduction

The Supreme Court has recently underscored for us the limited scope of our review when considering Social Security appeals, noting that:

The phrase "substantial evidence" is a "term of art" used throughout administrative law to describe how courts are to review agency factfinding. T-Mobile South, LLC v. Roswell, 574 U.S. —, —, 135 S. Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains "sufficien[t] evidence" to support the agency's factual determinations. Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S. Ct. 206, 83 L.Ed. 126 (1938) (emphasis deleted). And whatever the meaning of "substantial" in other contexts, the threshold for such evidentiary sufficiency is not high. Substantial evidence, this Court has said, is "more than a mere scintilla." Ibid.; see,e.g., Perales, 402 U.S. at 401, 91 S. Ct. 1420 (internal quotation marks omitted). It means—and means only—"such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."

Consolidated Edison, 305 U.S. at 229, 59 S. Ct. 206. SeeDickinson v. Zurko, 527 U.S. 150, 153, 119 S. Ct. 1816, 144 L.Ed.2d 143 (1999) (comparing the substantial-evidence standard to the deferential clearly-erroneous standard).

Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019).

In the instant case, Dale Walter applied for disability insurance benefits under Title II of the Social Security Act on October 29, 2015, alleging disability due to chronic arthritis, nerve damage, a shattered left heel, and other leg, back and neck problems. (Tr. 96). However, after a consideration of the medical evidence, which generally showed that Walter's pain was being managed with injections and medication, the Administrative Law Judge ("ALJ") who reviewed this case concluded that Walter could perform a limited range of sedentary work and denied his disability application.

Mindful of the fact that substantial evidence "means only—'such relevant evidence as a reasonable mind might accept as adequate to support a conclusion,'" Biestek, 139 S. Ct. at 1154, we find that substantial evidence supported the ALJ's findings in this case. Therefore, for the reasons set forth below, we will affirm the decision of the Commissioner denying this claim.

II. Statement of Facts and of the Case

On October 29, 2015, Dale Walter applied for disability benefits pursuant to Title II of the Social Security Act, alleging an amended onset date of disability beginning February 5, 2013 due to chronic arthritis, nerve damage, a shattered leftheel, and other leg, back and neck problems. (Tr. 96). Walter was approximately 45 years old at the time of the alleged onset of his disability and had prior employment as a roofer, which was medium skilled work but performed at a heavy exertional level. (Tr. 20). He had limited education and could communicate in English. (Id.).

Walter suffered from chronic back pain that was initially managed with narcotics. (Tr. 246). Then, in February of 2013, Walter suffered an injury to his foot at work when he fell in a hole. (Tr. 412). On February 28, 2013, Walter was seen by Dr. Mallhi, M.D., who noted that Walter was walking with crutches and he had pain when lifting, standing and sitting. (Id.) Dr. Mallhi recommended that Walter receive nerve blocks to control the neuropathic component of his pain. (Tr. 414). Walter then presented at Geisinger Woodbine Sports Medicine for a second opinion in March of 2013. (Tr. 238). It was noted that Walter had a fracture of calcaneus with flattening of Bohler angle, and he was using crutches and a CAM boot, but that his injury showed improvement and decreased swelling. (Tr. 238-39). Walter was seen by Dr. Roza at Mifflinville Family Practice on March 18, 2013, and it was noted that his pain was improving overall and there was decreased swelling. (Tr. 488). Dr. Roza opined that Walter would not be able to return to full construction work because he was non-weight bearing. (Tr. 490).

At an April 2013 consultation, it was noted that Walter was taking methadone and Percocet for breakthrough pain, and he was seeing a pain managementphysician. (Tr. 237). Dr. Cush did not recommend surgical intervention at that time. (Id.) At this time, Dr. Mallhi scheduled Walter for sacroiliac joint steroid injections. (Tr. 424). At follow-up appointments in May and June, Walter stated that the treatment had been controlling his pain and that he was able to perform his routine activities. (Tr. 419, 421). Walter also saw Dr. Cush at this time, who noted that Walter was using a cane to walk and that his pain was improving. (Tr. 235). Treatment notes indicate that Walter's x-ray showed no significant angular deformity. (Id.) At this visit, it was noted that Walter "may return back to work, light duty, and progress up to full duty as tolerated." (Id.) Additionally, in July of 2013, Dr. Ball., D.O., stated that Walter could return to work on July 22, 2014 with the following restrictions: no lifting more than forty pounds and limited ambulation. (Tr. 484).

Walter continued to treat with Dr. Mallhi for pain management related to his back and foot, and in September 2013, it was noted that the injections were working for temporary pain management, but that the pain gradually started to come back after a few weeks. (Tr. 425). Dr. Mallhi scheduled him for repeat peroneal nerve block and calcaneal bursa steroid injections. (Tr. 427). At a follow-up appointment in November, Walter stated that the injections again worked temporarily, but that the pain came back within a few weeks. (Tr. 428). Dr. Mallhi noted that any prolonged work at home or at his job, cold weather, and exercise increased his pain.(Id.) Treatment notes throughout January to June of 2014 generally described Walter's pain as throbbing or tingling and noted that the injections seemed to help with Walter's pain temporarily. (Tr. 431-41). Then in September 2014, Walter stated that his pain was better overall but flared up with changing weather. (Tr. 443). Indeed, Walter stated that his pain medications, heat, rest and massages made him feel better. (Id.) Moreover, while Walter generally stated that his pain was anywhere between a 6 to 9 out of 10, in November 2014, he reported that his pain was a 4 out of 10. (Tr. 449).

Walter continued to receive injections, and he reported in February 2015 that his pain was a 3-4 out of 10, and that he was very happy with the results of his treatment. (Tr. 455). In May of 2015, although reported his pain was a 7 out of 10, he stated that had been more active outside because the weather had been better. (Tr. 461). It was noted that Walter was using back brace while he was involved "in outdoor activities and more heavy physical work." (Tr. 462). In September 2015, an x-ray showed evidence of a previous calcaneus fracture with resulting subtalar joint arthritis and no significant angular deformity. (Tr. 232). Walter was prescribed a back brace and it was noted he was walking with a cane. (Id.)

It is against this clinical backdrop that a hearing was held on this disability application on January 25, 2018, where Walter appeared and testified, and a Vocational Expert also testified. (Tr. 26-66). Following this hearing, the ALJ issueda decision denying this application for benefits, finding that Walter remained capable of performing a range of sedentary jobs in the national economy in the representative occupations of document preparer, addresser, and final assembler. (Tr. 21).

In that decision, the ALJ first concluded the Walter had met the insured status requirements of the Social Security Act from the date of his amended onset of disability through September 30, 2015 and had not engaged in any substantial gainful activity since his amended alleged onset date of disability on February 3, 2015. (Tr. 14). At Step 2 of the sequential analysis that governs Social Security cases, the ALJ found that Walter suffered from the following severe impairments: osteoarthritis/calcaneal bursitis/sequela status - post left foot calcaneus fracture; degenerative disc disease and scoliosis of the cervical spine; degenerative disc disease and scoliosis of the thoracic spine; degenerative disc disease and scoliosis of the lumbar spine with post-laminectomy syndrome; and open fracture of the scaphoid bone of the right wrist. (Tr. 15). The ALJ also carefully considered a number of other impairments, but the ALJ ultimately concluded that these impairments did not limit Walter's ability to perform sustained work tasks more than minimally, and thus found these impairments to be non-severe. (Id.). At Step 3, the ALJ determined that none of these impairments met or medically equaled the severity of one of the listed impairments. (Tr. 15-16).

Between Steps 3 and 4, the ALJ fashioned a residual functional capacity ("RFC"), which considered all of Walter's limitations from his impairments:

After careful consideration of the entire record, the undersigned finds that, through the date last insured, the claimant had the residual functional capacity to perform sedentary work as defined in 20 C.F.R. 404.1567(a) except the claimant would have been limited to occupations that required no more than occasional postural maneuvers, such as balancing, stooping, and climbing on ramps and stairs, but must have avoided occupations that required climbing ladders, ropes, and scaffolds, or kneeling, crouching, or crawling. He must have avoided occupations that required pushing or pulling with the lower extremities to include the operation of pedals. The claimant must have avoided the operation of hand levers. He would have been limited to occupations that required no more

...