Williams-Ferguson v. Saul
| Decision Date | 29 July 2020 |
| Docket Number | 8:19-CV-468 |
| Parties | ELAINER N. WILLIAMS-FERGUSON, Plaintiff, v. ANDREW M. SAUL, Commissioner of Social Security; Defendant. |
| Court | U.S. District Court — District of Nebraska |
This matter comes before the Court on Elainer Williams-Ferguson's Motion for an Order Reversing the Commissioner of Social Security's Decision, Filing 14, which denied her application for disability-insurance benefits. The matter also comes before the Court on the Commissioner's Motion for an Order Affirming the Commissioner's Decision, Filing 16. For the reasons stated below, the Court grants the Commissioner's motion and denies Petitioner's motion.
Elainer Williams-Ferguson applied for disability-insurance benefits, alleging disability since April 5, 2016, due to fibromyalgia, bursitis in the hips, and migraines. Tr. 12, 237. She later amended her onset date to May 25, 2016. Tr. 12. The Social Security Administration denied her claim initially on August 18, 2016, and again upon reconsideration on January 26, 2017. Tr. 12. Williams-Ferguson requested a hearing, which was held on September 26, 2018, before an administrative law judge, David Buell ("the ALJ"). Tr. 32. The ALJ denied the claim on November 29, 2018, because Williams-Ferguson retained the residual functional capacity ("RFC") to perform other work existing in significant numbers in the national economy. Tr. 24-25. Williams-Ferguson now seeks review of the ALJ's decision as the final decision of the Commissioner under 42 U.S.C. § 405(g).
Williams-Ferguson had a long history of medical treatment, dating back to late 2015. Tr. 42, 337, 1200-03. On November 13, 2015, she underwent an extensive medical workup after reporting ongoing pain in her lower extremities, including a lumbar spine imaging that showed mild diffuse facet arthropathy with no clear etiology for her complaints of pain. Tr. 337. The lumbar magnetic resonance imaging ("MRI") scan was negative for any significant abnormalities and showed no disc degeneration or focal soft tissue disc protrusion. Tr. 337.
On December 23, 2015, rheumatologist Steven Wees, M.D., examined Williams-Ferguson and stated that he "did not think she had a rheumatologic, arthritic, or musculoskeletal basis for her lower extremity symptoms." Tr. 328-32. A physical examination revealed that she had a normal neck, clear lungs, normal cardiovascular functioning with normal heart sounds and rhythm, normal gait, and normal neurological functioning with intact motor strength, intact sensory functioning, and intact reflexes. Tr. 331. Dr. Wees reported that Williams-Ferguson's musculoskeletal examination was normal both in terms of axial and peripheral findings and had no trigger points. Tr. 331. Dr. Wees's rheumatologic examination was negative, and the only abnormality noted was a positive antinuclear antibody ("ANA") screen, which Dr. Wees did not believe was related to her reported symptoms. Tr. 332.
On March 11, 2016, Williams-Ferguson saw Dr. Scott Goodman, a neurologist at the Nebraska Medical Center, for headache management. Tr. 470. He noted that the neurological examination showed some pain-related abnormalities, while otherwise appearing normal. Tr. 472. Williams-Ferguson reported three to four headache days per week, with an average severity of sixout of ten and a severity of ten out of ten at their worst. Tr. 470. However, Dr. Goodman noted that the frequency was not certain since Williams-Ferguson did not track her symptoms. Tr. 470. Dr. Goodman asked her to keep a headache calendar for the three months until her next appointment. Tr. 472. He noted she "use[d] a combination of Maxalt and naproxen" for her headache treatment, which she described as being helpful. Tr. 470. She stated that after taking them, she "then takes herself to sleep for a while." Tr. 470.
On April 8, 2016, Williams-Ferguson went to the Midwest Pain Clinic and saw Richard Hubbell, M.D., who noted Williams-Ferguson had difficulty ambulating due to lower extremity pain as well as tenderness to multiple joints and muscles. Tr. 410, 413. He also noted a full range of motion in the upper extremities, lower extremities, and spine; negative straight leg raising; and normal sensory functioning and reflexes. Tr. 413. Dr. Hubbell diagnosed Williams-Ferguson with bursitis, hip pain, and fibromyalgia. Tr. 413. Dr. Hubbell continued prescriptions of Mobic, cyclobenzaprine, Lyrica, and Percocet. Tr. 413. He recommended a healthy diet and exercise. Tr. 413.
On April 25, 2016, at an annual physical with Dr. Christine Rahn, Williams-Ferguson reported doing well overall, that her symptoms were under better control since starting her medications, and that she was getting "migraines very infrequently." Tr. 499. The physical examination was normal with no tenderness, no swelling, and a normal range of motion in the musculoskeletal system. Tr. 501. Plaintiff also had normal sensory and motor functioning, no focal neurological deficits, and her "Cranial Nerves II-XII [were] grossly intact." Tr. 501.
On May 6, 2016, Williams-Ferguson returned to Dr. Hubbell and reported that her narcotic regimen was working well "at tolerating her pain." Tr. 415. She also reported that when she finished work her legs were usually pretty swollen, that she could not walk for long periods oftime due to pain, and that she had to stop every so often to sit down. Tr. 415. Otherwise, the physical examination remained unchanged. Tr. 418. Dr. Hubbell continued medications and suggested Williams-Ferguson wear TED hose while at work. Tr. 418.
On May 19, 2016, Williams-Ferguson returned to Dr. Hubbell and explained her pain medication was not helping enough and that her bilateral leg and hip pain had increased. Tr. 420. Dr. Hubbell started MS Contin and hydrocodone and noted that she had "been compliant with the medication regimen and treatment plan." Tr. 423-24. There was continuing joint and muscle tenderness as well as a full range of motion, intact sensation, and intact reflexes. Tr. 423.
On June 3, 2016, Williams-Ferguson returned to Dr. Hubbell and reported the current medications were working well at masking her pain, but she still had some pain. Tr. 425. She reported her legs were swollen from when she took a vacation. Tr. 425. Dr. Hubbell performed a bilateral greater trochanteric bursa injection and continued her medications. Tr. 428-29. He also noted that she was doing well and there were no changes besides increased pain in her hips. Tr. 429.
On June 10, 2016, Dr. Goodman noted that Williams-Ferguson appeared neurologically stable, although she reported being on medical leave from work for the past two or three weeks due to her severe hip and lower extremity pain. Tr. 452. She reported "off and on" headaches seven to ten days per month, but indicated she had given up on her headache calendar and had not brought it with her. Tr. 452. Dr. Goodman noted that she walked with a cane and had a "cautious" and "slightly staggering" gait but was able to walk independently for a short distance. Tr. 453. Dr. Goodman recommended no medication changes at that time and again encouraged Williams-Ferguson to keep a headache diary. Tr. 454.
On June 30, 2016, Williams-Ferguson completed a questionnaire for the Social Security Disability Examiner. Tr. 260-64. She reported that her activities were limited and that she could stand for no longer than five minutes due to pain and swelling. Tr. 260-61. She stated that she had good and bad days. Tr. 260-62. On better days, she could walk on the treadmill, go grocery shopping, cook a meal, do laundry, and vacuum, although pushing the vacuum would cause her pain. Tr. 260-63. On worse days she reported having to lay in bed all day. Tr. 261-62. She stated she could sit for thirty to sixty minutes at a time before her hip started to hurt. Tr. 261.
On July 19, 2016, Williams-Ferguson sought emergency-room treatment for her hip pain. Tr. 940. She received a Toradol and Dilaudid injection and was prescribed prednisone and ondansetron. Tr. 942. On August 21, Williams-Ferguson again sought emergency-department treatment for bilateral leg pain, although her legs appeared normal on inspection. Tr. 936, 938. She was provided another Toradol injection. Tr. 938.
On August 24, 2016, Williams-Ferguson reported pain at six out of ten, so Dr. Hubbell increased her hydrocodone. Tr. 609, 613. On August 26, 2016, Dr. Rahn noted tenderness from palpation throughout Williams-Ferguson's legs and a limited range of motion due to pain in her hips, knees, and ankles. Tr. 704. Williams-Ferguson explained that physical therapy had been too painful, so Dr. Rahn recommended aquatic physical therapy. Tr. 704.
On October 15, 2016, Williams-Ferguson sought emergency-department treatment for bilateral hip and leg pain. Tr. 932. On October 17, 2016, Dr. Joel Cotton wrote a letter to Dr. Rahn explaining that based upon his review of Dr. Goodman's records, he believed there was not a neurological explanation for Williams-Ferguson's pain or apparent inability to function. Tr. 948. He explained that nothing further was planned from a neurologic standpoint for Williams-Ferguson's leg and hip pain. Tr. 948.
On December 6, 2016, Williams-Ferguson saw Dr. Jeremy Gallant, an orthopedist, who diagnosed myalgia and explained that her exam was remarkable for suspected facet arthropathy bilaterally, which could cause her back and gluteal pain. Tr. 767, 769. Furthermore, Dr. Gallant explained that her trochanteric bursa symptoms were a side effect of her "severely altered gait pattern." Tr. 767. Furthermore, he noted that Williams-Ferguson underwent a lower extremity electromyography ("EMG") procedure that was normal bilaterally; diagnostic lab work that was normal aside from a positive ANA; and imaging of the hip and pelvis that revealed some degenerative changes in the facets but was otherwise unremarkable. Tr. 765. Dr. Gallant prescribed water-based...
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