United States District Court, M.D. Tennessee, Nashville Division
RHONDA L. UNDERWOOD, Plaintiff,
SOCIAL SECURITY ADMINISTRATION, Defendant.
William J. Haynes, Jr. Senior Judge
Rhonda L. Underwood, filed this action under 42 U.S.C.
§§ 405(a) and 1383(c)(3) against the Defendant
Carolyn W. Colvin, Acting Commissioner of the Social Security
Administration, seeking judicial review of the
Commissioner's denial of Plaintiff s applications for
disability benefits under Title II and XVI of the Social
Security Act. Plaintiff filed her application on April 20,
2010, alleging disability since April 19, 2010 based upon her
severe back pain, lumbar spine impairments, hypertensive
cardiovascular disease, and hypertension. (Docket Entry No.
12, Administrative Record, at 213-220, 248). Plaintiffs
applications were denied initially, and after
reconsideration. Id. at 106-08, 110-11. Plaintiff
requested a hearing before an Administrative Law Judge
("ALJ") and by decision dated March 5, 2012, ALJ
Roberts found Plaintiff had severe impairments, but retained
the ability to perform light work. Id. at 84-99.
Plaintiff requested review of the AL J's decision by the
Appeals Council that ordered a remand for a new hearing.
Id. at 100-03.
second hearing, the ALJ found Plaintiff was not disabled and
was able to perform light work. Id. at 5-34.
Plaintiff requested a review by the Appeals Council that the
Appeal Council denied. Id. at 1-5.
the Court is the Plaintiffs motion for judgment on the
administrative record (Docket Entry No. 14) contending, in
sum, that the AL J erred in evaluating the opinions of
Plaintiff s treating physicians and Plaintiffs credibility.
The Commissioner responded (Docket Entry No. 17) that the ALJ
properly evaluated the evidence and his decision is supported
by substantial evidence.
Review of the Record
a high school graduate, was 45 years old at the onset of her
disability. (Docket Entry No. 12, Administrative Record, at 3
9-40). Plaintiff s past relevant work was as a packer and
cashier. M. According to Plaintiffs testimony, after back
surgery in 2007, she was unable to work due to severe and
sharp pain in her back. Id, at 44, 48. Plaintiff
testified that she can sit and stand for 15-20 minutes when
her pain bothers her and she must change positions.
Id. at 44-45. Plaintiff can lift five pounds.
Id. at 46. Plaintiff, who had carpal tunnel surgery
in 1997 or 1998, cannot lift over 10 pounds with her right
hand and was receiving injections into her right hand and
wearing a brace at night to avoid hand pain. Id. at
64. Despite hip surgery in 2008, Plaintiff had left-sided hip
pain. Id. at 47-49. Plaintiff has received
injections and used a TENS unit without relief. Id.
at 49-50. Plaintiff sleeps for a couple of hours and then is
awake for two or three hours. Id. at 50. Lack of
sleep causes Plaintiff daytime fatigue that has not been
alleviated by any treatment. Id. at 50-51.
home, Plaintiff tries to sweep or mop, but doing so causes
back pain and requires rest. Id. at 44. Plaintiff
cannot write for very long due to hand pain, and often drops
items if she does not use bothhands. Id. at 69.
Plaintiffs medications help her symptoms, but these effects
wear off if Plaintiff tries to do housework. Id. at
70. Plaintiff lies down three-fourths of the day to relieve
her pain. Id.
September 5, 2007, Plaintiff had an L4-L5 laminectomy for low
back pain that radiated down her left leg. Id. at
358. On February 25, 2008, Plaintiff began treatment with
Pain Management Specialist William H. Leone, M.D., of the
Pain Management Group. Id. at 667. Dr. Leone also
treated Plaintiff for cervical spondylosis and, on December
9, 2009, administered left C4, C5, and C6 medial branch nerve
block. Id. at 596. On February 3, 2010, Dr. Leone
performed a left C4, C5, medial branch nerve rhizotomy.
Id. at 591. In a follow-up procedure on March 2,
2010, Plaintiff responded that the rhizotomy helped her neck
pain and mobility, but her left arm heaviness and left
shoulder pain remained. Id, at 587-90. Dr. Leone
refilled her medications of Lortab and Neurontin, but added
Robaxin. Id. at 590, 615. On March 30, 2010,
Plaintiff reported a continued "heavy" feeling in
her left arm and a physical examination revealed tenderness
and increased tone in the cervical paraspinal muscles.
Id. at 583-86. Dr. Leone refilled Plaintiffs
medications and ordered an updated MRI of her cervical spine.
April 27, 2010, the MRI revealed posterior disc protrusions
at C2-C3, C3 -C4, C4-C5, and C5-C6 causing mild compression
of the spinal cord at C4-C5 and C5-C6. Id. at 578.
Plaintiff also had a diffuse disc bulge at C6-C7 and
bilateral uncovertebral osteophytes causing mild central
stenosis and bilateral foraminal narrowing. Id. Dr.
Leone also ordered refills of Plaintiffs medications.
Id. at 582.
25, 2010, Plaintiff cited increased neck pain upon turning to
the left and Dr. Leone noted that past epidural injections
had not helped in the long term. Id. at 574-77. Dr.
Leone refilled her medications and recommended IFC treatment.
Id. at 577. On June 22, 2010, Plaintiff reported to
Dr. Leone that she was attending physical therapy and using
her TNS unit, but standing, lifting, bending, and sitting for
too long increased her pain. Id. at 571. Dr. Leone
refilled her medications, recommended a functional capacity
evaluation, and would consider repeating prior procedures as
needed. Id. at 573.
June 22, 2010 letter, Malinda Johnson PAC, Dr. Leone's
assistant, described Plaintiffs history of treatment at The
Paint Management Group for chronic neck and low back pain,
Id. at 569, that remained unchanged on My 20, 2010
and August 17, 2010. Id. at 562-68. Plaintiffs
medications were refilled. Id., On September 14, 2010,
Plaintiff returned to the clinic complaining of increased low
back pain radiating to her right lower extremity.
Id. at 558. Dr. Leone ordered an updated MRI of
Plaintiff s lumbar spine. Id. at 560. On November 9,
2010, Plaintiff reported increased neck pain and her
inability to afford physical therapy. Id. at 548.
Plaintiff also reported symptoms of low back pain and
bilateral lower extremity pain that worsen with walking.
Id. Dr. Leone prescribed lumbar epidural steroid
injections that Plaintiff received on November 24, 2010,
December 8, 2010, and December 19, 2010. Id. at
February 3, 2011, Dr. Leone refilled Plaintiffs Lortab,
prescribed Mobic, and recommended physical therapy.
Id. at 532-34. On February 25, 2011, Plaintiff
received trigger point injections to her trapezii and
supraspinatus areas. Id. at 529. On March 3, 2011,
Plaintiff received medication refills. Id. at
525-27. On April 28, 2011, Plaintiff returned to Dr. Leone
for additional refills and physical examination that revealed
tenderness in the cervical and lumbar paraspinal muscles.
Id. at 518-20.
October 13, 2011, Plaintiff experienced severe and worsening
pain throughout her spine and both legs as well as difficulty
falling asleep. Id. at 697. Elizabeth Bruce, PAC,
examined Plaintiff on October 13, 2011 and December 8, 2011
and found cervical and lumbar spine tenderness. Id.
at 693-98. Bruce prescribed Lortab, Robaxin, and Neurontin,
ordered an MRI of Plaintiffs thoracic spine, and recommended
additional lumbar epidural injections. Id. at 695.
The December 23, 2011 MRI revealed a left paracentral disc
protrusion at T7-T8 of Plaintiff s spine. Id. at
August 20, 2014, Dr. Leone performed a functional capacity
evaluation. Id. at 1085-1103. Based upon the test
results, Dr. Leone opined that Plaintiff was unable to
perform stooping, kneeling, crouching, lifting or carrying
more than ten pounds, pushing or pulling more than ten
pounds, reaching with the left arm, or rotating the cervical
spine left or right. Id. at 1085. Dr. Leone cited
very decreased flexion and extension in Plaintiffs lumbar
August 25, 2014, Dr. Leone completed a Disability Impairment
Questionnaire summarizing Plaintiff s condition, citing his
diagnoses of brachial neuritis, lumbosacral neuritis and
spondylosis, cervical spinal stenosis and spondylosis,
shoulder joint pain, thoracic spine pain, myalgia and
myositis, and facet syndrome. Id. at 1110-14.
Plaintiff s primary symptoms were chronic pain in her neck,
left shoulder, and lumbar spine that have been present since
September 3, 2007. Id. at 1111, 1114. In Dr.
Leone's opinion, Plaintiff could sit for up to one hour
total and stand/walk for up to one hour total in an eight
hour day. Id. at 1112. Dr. Leone recommended that
when sitting for 10-15 minutes, Plaintiff should get up and
move around every 20 minutes before returning to a seated
position. Id. Dr. Leone stated Plaintiff could lift
and carry up to ten pounds occasionally and could only work
for 1/3 of an eight-hour day where the job would involve
reaching in all directions and manipulation. Id. at
1112-13. Plaintiffs pain, fatigue, and other symptoms would
limit her attention and ...