United States District Court, M.D. Tennessee, Nashville Division
Honorable Aleta A. Trauger, United States District Judge.
REPORT AND RECOMMENDATION
BROWN United States Magistrate Judge.
Plaintiff brings this action under 42 U.S.C. § 405(g),
seeking judicial review of the Social Security
Commissioner's denial of his application for disability
insurance benefits under Title II of the Social Security Act,
42 U.S.C. §§ 401-434. For the following reasons,
the Magistrate Judge RECOMMENDS that the
Plaintiff's motion for judgment on the administrative
record (Doc. 14) be DENIED and the
Commissioner's decision be AFFIRMED.
2011, the Plaintiff applied for disability insurance
benefits, alleging an onset date of March 1, 2011. (Doc. 10,
pp. 79, 175). His applications were denied on initial
review and again upon reconsideration. (Doc. 10, pp. 79-80,
83, 90). Two administrative hearings were convened at the
Plaintiff's request. (Doc. 10, pp. 25-78). The
administrative law judge (“ALJ”) issued an
unfavorable decision (Doc. 10, pp. 7-24) which the Appeals
Council declined to review (Doc. 10, pp. 1-3). Thereafter,
the Plaintiff filed a complaint seeking review of the
ALJ's decision. (Doc. 1). This case was referred to the
undersigned pursuant to Rule 72 of the Federal Rules of Civil
Procedure and 28 U.S.C. § 636(b)(1)(A)-(B). (Doc. 3).
Pending now is the Plaintiff's motion for judgment on the
administration record (Doc. 14) to which the Defendant
responded (Doc. 16) and the Plaintiff replied (Doc. 17).
REVIEW OF THE RECORD
Premier Orthopaedics & Sports Medicine, PLC, July 1999
through March 2005
Plaintiff presented to Premier Orthopaedics & Sports
Medicine, PLC from July 1999 to March 2005. (Doc. 10, pp.
790-839). He underwent a rotator cuff surgery on his left
shoulder in 2000 and was treated for right shoulder pain,
left wrist pain, and left shoulder pain residual from repeat
rotator cuff repair. (Doc. 10, pp. 790-839).
Affiliated Internists, February 2008 through May
2008 to 2010, Dr. Travis Pardue, M.D., treated the Plaintiff
for major depressive disorder, severe degenerative disc
disease, lumbago of the lumbar and cervical spine,
post-laminectomy syndrome, paraspinal muscle pain and
tenderness, finger pain, inflammatory arthritis, joint pain,
cervical spondylosis and radiculopathy, cervicalgia, and
lumbar radiculopathy. (Doc. 10, pp. 332-523). Assessments of
the Plaintiff during these visits generally showed normal
muscular findings with a normal gait and station, normal
neurological findings, and normal psychological findings.
(Doc. 10, pp. 356-523). An MRI of the Plaintiff's
cervical spine on March 10, 2010 revealed mild spinal
stenosis on several levels, most pronounced at ¶ 3-C4,
and foraminal stenosis at several levels, worse on the left
at ¶ 6-C7. (Doc. 10, p. 586).
Plaintiff saw Dr. Pardue approximately once a month from 2011
to 2013. He generally denied depression. (Doc. 10, pp. 540,
542, 549, 553, 633, 635, 638, 644, 654, 664, 673, 682, 687,
701). Exam notes continued the trend of normal muscular
findings with a normal gait and station, normal neurological
findings, and normal psychological findings. (Doc. 10, pp.
533, 539, 542-543, 545-547, 550, 551-554, 634-636, 638-640,
642, 644, 652, 654, 656, 658, 660, 662, 664, 682, 685, 698).
When assessed, the Plaintiff had full strength and normal
bulk and tone in his right upper extremity, left upper
extremity, right lower extremity, and left lower extremity.
(Doc. 10, pp. 542-543, 551-554, 635-636, 698). On occasion,
the Plaintiff presented with disturbed gait or station, spine
deformity or tenderness, or decreased extension, flexion,
lateral bending, and rotation. (Doc. 10, pp. 525, 541, 552,
634, 640, 660, 664, 698, 701, 703).
Plaintiff repeatedly reported that his medications
effectively controlled his pain, produced no side effects,
and permitted him to function better and perform activities
of daily living. (Doc. 10, pp. 639, 641, 643, 653, 659, 661,
663, 665). On one occasion, the Plaintiff reported a new
medication made him groggy and thereafter switched to his
original medication. (Doc. 10, p. 653).
January 2013 cardiopulmonary exercise test indicated that the
Plaintiff could sustain light activity, such as desk work,
constantly during the day, and could perform various jobs,
like bartending or driving a heavy truck, in an eight-hour
workday. (Doc. 10, p. 690). The reviewer noted that the
Plaintiff ended the test early because of complaints of back
pain and fatigue and recommended the Plaintiff be placed in
an exercise program. (Doc. 10, p. 689).
Pinnacle Wellness Group, July 2013 through July 2014
July 2013 to July 2014, the Plaintiff attended Pinnacle
Wellness Group on a monthly basis for chronic pain management
after trying previous treatments, including a back brace,
facet and epidural injections, medications, surgery, physical
therapy, and a TENS unit. (Doc. 10, pp. 709-785, 840-972). He
was treated by a board certified family nurse practitioner.
records show reports of knee, neck, and back pain on a scale
of 5 to 8 out of 10; normal gait, neurological findings, and
psychological findings; tender spine, facet joints, and
sacroiliac joints; decreased rotation; abnormal Schober's
test; and positive straight leg raise. (Doc. 10, pp. 709-
716, 719-726, 729-736, 739-745, 748-755, 758-774, 776-780,
drug testing showed the presence of medication that was not
prescribed, including: Butalbital, Nordiazepam, Oxazepam,
Temazepam, Fentanyl, and Norfentanyl. (Doc. 10, pp. 717-718,
727-728, 737-738, 746-747, 756-757).
Reports from the Plaintiff and His Wife
Plaintiff alleged disability on account of degenerative disc
disease, major depression, lumbar spinal stenosis, rheumatoid
arthritis, and poor vision. (Doc. 10, p. 201). He takes care
of a pet with help, must get up every thirty minutes which
disrupts his sleep, prepares light meals two times a week,
can fold laundry and dust in short periods with
encouragement, goes outside five times a week, can ride in a
car but cannot drive, can go out alone, has no trouble
handling money, watches television and listens to online
radio shows every day, talks on the phone for a limited time,
and needs accompaniment for social activities. (Doc. 10, pp.
220-223). He indicated that his conditions affect his ability
to lift, squat, bend, stand, reach, walk, sit, kneel, climb
stairs, concentrate, and follow instructions. (Doc. 10, p.
224). He stated he can walk 100 yards before needing to stop
and rest for thirty minutes, can only pay attention for
thirty minutes, follows instructions relatively well, gets
along with authority figures, and does not handle changes in
routine well. (Doc. 10, pp. 224-225). He uses prescription
glasses, a cane, and a brace or splint while outside his
home. (Doc. 10, p. 225).
2011, he claimed his back was more painful, he was more
depressed, and his medication caused blurry vision and
difficulty focusing. (Doc. 10, pp. 212-213). In December
2011, he stated that he can only stand twenty minutes, walk
twenty minutes at a time, and stay on his feet no more than
one hour per day. (Doc. 10, p. 234).
Plaintiff's wife also filled out a function report in
December 2011. (Doc. 10, pp. 236-243). The report is
generally consistent with the Plaintiff's except his wife
stated he makes light meals weekly, only leaves the house
once per month, cannot handle most monetary functions, has
trouble seeing, with memory, completing tasks, and
understanding, has trouble getting along with authority
figures, and does not use a brace or splint. (Doc. 10, pp.
Medical Source Statements from Dr. Pardue
Pardue, an internal medicine specialist, filled out a medical
source statement for the Plaintiff in May 2011. (Doc. 10, pp.
284-293). He opined that the Plaintiff can occasionally lift
and carry up to 10 pounds due to lumbar back pain. (Doc. 10,
p. 284). Because of the Plaintiff's multiple lumbar back
surgeries, he can sit 30 minutes at a time, stand 15 minutes
at a time, and walk fifteen minutes at a time; sit two hours
in an eight hour day, stand 15 minutes in an eight hour day,
and walk 15 minutes in an eight hour day; must use a cane to
ambulate more than 100 yards; and can carry small objects
with his hands when not using a cane. (Doc. 10, p. 285). He
can only occasionally use his hands because of cervical
degenerative disc disease and only occasionally use his feet
because of osteoarthritis. (Doc. 10, p. 286). He can never
climb ladders, balance, or crawl, and can occasionally climb
stairs, stoop, kneel, and crouch. (Doc. 10, p. 287). The
Plaintiff can never tolerate unprotected heights or moving
mechanical parts and occasionally tolerate other
environmental limitations. (Doc. 10, p. 288). The noise level
should be akin to a library. (Doc. 10, p. 288). The Plaintiff
cannot shop, travel without a companion, walk a block at a
reasonable pace on rough or uneven surfaces, climb a few
steps at a reasonable pace with the use of a single hand
rail, or prepare simple meal and feed himself. (Doc. 10, p.
289). He can ambulate without using a wheelchair, walker, two
canes, or two crutches; use standard public transportation,
care for personal hygiene, and sort, handle, and use paper
files. (Doc. 10, p. 289). Due to medication, the Plaintiff is
markedly impaired in his ability to make judgments on complex
work-related decisions, mildly impaired in his ability to
understand and remember complex instructions, and moderately
impaired in other memory and social interaction functions.
(Doc. 10, pp. 291-292). According to Dr. Pardue, the
Plaintiff has suffered from these physical and mental
limitations since 1995. (Doc. 10, pp. 289, 292).
Pardue completed a second medical source statement on January
7, 2014. (Doc. 10, pp. 705-708). He opined the Plaintiff can
occasionally and frequently lift and carry less than ten
pounds, stand or walk for less than two hours in an
eight-hour workday, sit less than six hours in an eight hour
workday, and has a limited ability to push and pull with
upper and lower extremities. (Doc. 10, pp. 705-706). These
opinions were supported by the Plaintiff's severe lumbar
back pain, severe lumbar tenderness, positive straight leg
raise, multiple lumbar surgeries, and MRI results. (Doc. 10,
p. 706). He opined the Plaintiff can never climb stairs or
stoop and can only occasionally balance, kneel, crouch, or
crawl due to his severe lumbar back pain “that limits
him from doing anything.” (Doc. 10, p. 706). Due to
cervical spinal stenosis, foraminal stenosis, and
osteoarthritis in his hand, the Plaintiff can constantly
feel, but only occasionally reach, handle, and finger
objects. (Doc. 10, p. 707). Dr. Pardue identified no visual,
communicative, or environmental limitations. (Doc. 10, pp.
Reports from State Examiners
Horace Edwards, Ph.D., completed a psychiatric review
technique and mental residual functional capacity
(“RFC”) assessment in September 2011. (Doc. 10,
pp. 299-316). He found mild restriction in activities of
daily living, moderate difficulty maintaining social
functioning and maintaining concentration, persistence, and
pace, and no episodes of decompensation. (Doc. 10, p. 309).
Giving controlling weight to Dr. Pardue's opinion, Dr.
Edwards concluded that the Plaintiff can understand and
remember simple, detailed, and multi-step detailed tasks, but
not at an executive level; concentrate and persist for
simple, detailed, and multi-step detailed tasks without
significant difficulty with appropriate breaks; interact
appropriately with the public, ...