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Trobaugh v. Saul

United States District Court, M.D. Tennessee, Northeastern Division

September 13, 2019

ANDREW M. SAUL, [1]Commissioner of Social Security, Defendant.

          Honorable Waverly D. Crenshaw, Jr., Chief United States District Judge



         Pending before the court is Plaintiff's motion for judgment on the administrative record (Docket Entry No. 16), to which Defendant Commissioner of Social Security (“Commissioner”) filed a response (Docket Entry No. 22). Upon consideration of the parties' filings and the transcript of the administrative record (Docket Entry No. 10), [2] and for the reasons given herein, the Magistrate Judge RECOMMENDS that Plaintiff's motion for judgment be GRANTED and that the decision of the Commissioner be REVERSED and REMANDED for further administrative proceedings consistent with this Report and Recommendation.


         Plaintiff, John Thomas Trobaugh, filed an application for Disability Insurance Benefits (“DIB”) under Title II and an application for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act on May 20, 2015, alleging disability onset as of April 1, 2014, due to back, shoulder, carpal tunnel, and diabetes. (Tr. 10, 68, 249, 254). Plaintiff's claim was denied at the initial level on September 15, 2015, and on reconsideration on December 10, 2015. (Tr. 10, 128, 138). Plaintiff subsequently requested de novo review of his case by an administrative law judge (“ALJ”). (Tr. 10, 145). The ALJ heard the case on April 17, 2017, when Plaintiff appeared with counsel and gave testimony. (Tr. 10, 29-67). Testimony was also received by a vocational expert. (Tr. 64-66). At the conclusion of the hearing, the matter was taken under advisement until October 31, 2017, when the ALJ issued a written decision finding Plaintiff not disabled. (Tr. 10-24). That decision contains the following enumerated findings:

1. The claimant meets the insured status requirements of the Social Security Act through June 30, 2020.
2. The claimant has not engaged in substantial gainful activity since April 1, 2014, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq.).
3. The claimant has the following severe impairments: right shoulder dysfunction, lumbar degenerative disc disease, bilateral carpal tunnel syndrome (CTS), diabetes mellitus, obesity, affective disorder, anxiety disorder, and alcohol abuse disorder (20 CFR 404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
5. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except he can only occasional push, pull, and reach with his right upper extremity and he can only occasionally climb ladders, ropes, or scaffolds. Mentally, he can perform simple and detailed, 1-4 step tasks. Additionally, he can sustain occasional contact with supervisors, coworkers, and the public and he can adapt to gradual and infrequent changes in the work routine.
6. The claimant is unable to perform any past relevant work (20 CFR 404.1565 and 416.965).
7. The claimant was born on June 6, 1972 and was 41 years old, which is defined as a younger individual age 18-49, on the alleged disability onset date (20 CFR 404.1563 and 416.963).
8. The claimant has at least a high school education (20 CFR 404.1564 and 416.964).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is “not disabled, ” whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).
10. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569, 404.1569(a), 416.969, and 416.969(a)).
11. The claimant has not been under a disability, as defined in the Social Security Act, from April 1, 2014, through the date of this decision (20 CFR 404.1520(g) and 416.920(g)).

(Tr. 12, -13, 14-15, 22-23, 24).

         On April 24, 2018, the Appeals Council denied Plaintiff's request for review of the ALJ's decision (Tr. 1-5), thereby rendering that decision the final decision of the Commissioner. This civil action was thereafter timely filed, and the Court has jurisdiction. 42 U.S.C. §§ 405(g) and 1383(c)(3).


         The following summary of the medical record is taken from the ALJ's decision:

The medical record shows the claimant sought treatment for his right shoulder following his injury. Initially he reported pain and intermittent burning. However, on examination he had only mild tenderness with full range of motion, normal strength, and negative orthopedic signs. An x-ray of his shoulder was also negative (Ex. 3F, p. 31). The claimant also had a magnetic resonance imaging (MRI) scan of his shoulder that showed his rotator cuff was intact and he had only mild acromioclavicular degeneration. However, the study also showed a superior labral abnormality with a lesion and paralabral cyst (Ex. 1F, p. 3). He started physical therapy but was discharged due to non-compliance (Ex. 4F, pp. 16-17). Subsequently, he met with an orthopedic surgeon who recommended surgery (Ex. 4F, p. 8).
In July 2014, the claimant had arthroscopic surgery on his right shoulder, including labral repair with decompression and debridement (Ex. 4F, p. 18). During his follow up examinations, he showed limited range of motion and residual weakness. However, his doctor also noted that he had not started physical therapy as advised. The doctor also noted that his lack of physical therapy was compromising his recovery (Ex. 4F, p. 10). When the claimant finally started physical therapy, he showed improvement (Ex. 4F, p. 11).
In February 2015, the claimant attended his last treatment appointment for his right shoulder. He continued to report residual pain and limited range of motion. However, he showed no joint instability and he had a negative O'Brien's test. The claimant's surgeon also released him to return to work but gave him a permanent lifting restriction of 35 pounds with only 15 pounds lifting overhead (Ex. 4F, p. 14). The claimant testified at the hearing that he has not returned to see his surgeon since February 2015, and he attributed this lack of treatment to financial difficulties (Hearing Testimony).
In July 2015, Thomas Dake, M.D., an independent consultant, examined the claimant. The claimant reported residual right shoulder pain, as well as lower back pain, chronic joint pain, bilateral wrist pain, and elevated blood sugars. However, on examination, Dr. Dake noted the claimant had good blood pressure, normal cardiovascular findings, and he admitted he had not taken his diabetes medication for several months. Dr. Dake also found the claimant had limited range of motion in his right shoulder but otherwise full range of motion in all extremities. Additionally, the claimant was missing reflexes, but he had a normal gait, his sensation was normal, and he had 5/5 motor strength throughout (Ex. 5F, pp. 1-4).
The claimant also started treatment for his back pain in November 2015. An x-ray of his back showed only mild spondylosis and loss of disc height at the L3-5 vertebra (Ex. 13F, p. 3). When he started physical therapy he had bilateral radiculopathy and mild weakness, but his therapist noted he had an excellent prognosis (Ex. 22F, pp. 1-3). The only additional back pain treatment that the claimant has received has been conservative medication management. He has not required any epidural steroid injections, emergency room visits, or surgical intervention (Hearing Testimony).
In January 2016, he had an MRI scan of his lumbar spine. That study showed disc degeneration at the L3-5 vertebra with a protrusion at the L4-5 level resulting in mild to moderate stenosis (Ex. 13F, p. 1).
In March 2016, the claimant reported worsening back pain to his primary care physician, but he also admitted he was not taking any medication. His doctor recommended medication and gave him a referral for a surgical consultant (Ex. 16F, p. 6). The surgeon noted some lumbar tenderness and decreased range of motion, but also found the claimant had normal sensation, negative straight leg raising, and 5/5 motor strength throughout. He concluded that there was nothing in the radiographic imaging to correlate to the claimant's ...

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